Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient Hospital
The insurer denied the inpatient hospital stay.
The health plan's determination is upheld.

The patient is a male that presented to the emergency department (ED) with a one-day history of right lower quadrant pain with walking/coughing/urinating, nausea, and decreased appetite. He was taken to the pediatrician that advised them to seek out ED evaluation if symptoms worsen. His vital signs included temperature 36.6, heart rate 65, respiratory rate 19, and blood pressure 115/72. The examination was significant for right lower quadrant tenderness, clear lungs, regular heart rate and rhythm, and non-focal neurologic exam. While in the ED, he developed guarding in addition to tenderness.
A computed tomography (CT) of the abdomen and pelvis was obtained that showed no signs of acute appendicitis but large amount of stool consistent with constipation. He was transferred to another ED for surgical evaluation. The laboratory evaluation was significant for a white blood cell count (WBC) 8.0, negative viral screen, and an unremarkable metabolic panel. He was admitted for monitoring. The admission orders included nothing by mouth, intravenous (IV) fluids, Tylenol as needed for pain, ambulation as tolerated, serial abdominal exams. His diet was advanced and tolerated without nausea or vomiting, and he was able to pass flatus. His abdominal pain improved over the course of the day, and he was deemed stable for discharge.

The acute inpatient hospital admission was not medically necessary. Acute abdominal pain is a very common complaint in children. The differential diagnosis is quite broad, including infectious causes (e.g., Coronavirus (Covid19) infection, group A Streptococcal infection including pharyngitis), structural abnormalities, renal causes such as stones, constipation, behavioral/emotional issues, inflammatory diseases, and diseases associated with malabsorption. History, physical examination findings, laboratory evaluation, and radiographic studies provide additional clues to the etiology. Radiographic studies include plain x-rays, ultrasound, and CT scan with and without contrast.
Constipation is not uncommon in childhood, and at times may be severe. It is typically functional. Functional constipation is a very common problem in childhood, with a worldwide prevalence of about 3 percent (%). In up to 40% of children, constipation begins in the first year of life. Constipation is typically associated with painful stooling, abdominal pain, stool incontinence, and infrequent stooling. Most children that present with this constellation of symptoms have no significant underlying medical etiology.
This patient presented to the ED with abdominal pain, nausea, and decreased appetite. He underwent work-up for possible appendicitis and was noted to have significant constipation. He was admitted for monitoring and serial examinations. While it was not unreasonable to observe him for resolution versus worsening of his pain, he was overall hemodynamically stable, with no evidence of obstruction or other abdominal catastrophe, with appendicitis ruled out, and no significant dehydration. He did not require acute inpatient admission and could have been safely managed at lower level of care.

The health plan's determination of medical necessity is upheld in whole.