Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain 

Treatment: Inpatient admission

The insurer is denied coverage for inpatient admission.
The denial is upheld. 

The patient was then a female child with an unremarkable past medical history who presented to the Emergency Department (ED) for assessment of diffuse abdominal pain for the past 8 days with worsening in the last 24 hours. The patient's pain was associated with nausea without vomiting and was worse with jumping. There was no associated fever, bleeding, weight loss, dysuria, or sick contacts. Of note, the patient also noted a dry cough for the past several weeks. The patient had been evaluated with similar complaints in the same Emergency Department with a computed tomography (CT) scan showing a normal appendix and a small amount of pelvic fluid. The patient's vital signs on arrival were notable for heart rate of 70, temperature of 98.7 F, respiratory rate of 20, and blood pressure of 111/75 and room air oxygen saturation of 100%. The patient's admitting weight was 34.7 kilograms and her height was 135 centimeters. The patient's physical exam was notable for a well-developed, well-nourished female in no apparent distress; the patient had moist mucosa, normal skin turgor, normal capillary refill and warm skin; the patient's lungs were clear; the patient's cardiac exam was unremarkable. 

The patient's abdominal exam was notable for normal bowel sounds and was soft; there was tenderness to palpation in the bilateral lower quadrants, right more than the left, and on the suprapubic region; no organomegaly, distension, rebound, or guarding was evident. A gastroenterology phone consult recommended checking a CRP and ESR. Despite improvement in pain, it was decided to admit the patient to the inpatient service for observation and pain control. The patient was given a regular diet for which she continued to tolerate well. No additional pain medications were required. No antibiotics were given. The patient's only inpatient treatment was a single dose of Zofran. The patient was never evaluated by surgery. The patient's maximum temperature was 99.3 during this short inpatient stay. The patient did not vomit and her pain was improving. No repeat laboratories were performed. The patient was discharged for outpatient follow-up. 

This patient did not require a surgical intervention once her repeat computed tomography (CT) excluded serious causes of abdominal pain. The patient's vitals, physical exam, laboratories, imaging and course over time while in the Emergency Department suggested that she could have been managed in the observational setting effectively and safely. Effective oral hydration and analgesics could have been administered to a non-vomiting patient with nausea responsive to anti-emetics. In fact, this patient actually never received any acute care other than a single dose of Zofran. No advanced medical monitoring was required or delivered. The patient did not meet any of the listed criteria for acute level of care. In conclusion, the acute inpatient admission from was not medically necessary for this patient.

The health plan acted reasonably with sound medical judgment, and in the best interest of the patient. 

Based on the above, the medical necessity for the inpatient admission is not substantiated. The insurer's denial should be upheld.