Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastrointestinal/Abdominal/Stomach Pain
Treatment: Full Hospital Admission
The health plan denied the requested full hospital admission as not medically necessary. The health plan's determination is upheld.

This patient is under consideration of medical necessity for admission to acute inpatient level of care. This patient is a female who presented at 23-4/7 weeks gestational age with complaints of 8/10 abdominal pain with nausea and vomiting. She had epigastric pain that started that had moved to the right lower quadrant. The patient reported the pain to be sharp and constant. She tried Tylenol but that had not improved the pain. She had an episode of vomiting. She had shivering on the way to the hospital. The patient had no fever. She had no changes in bowel patterns, continued to pass gas, and had normal urinary patterns. She denied headaches, changes in vision, shortness of breath, or chest pain. The patient had a temperature of 97F (degrees Fahrenheit) with a normal blood pressure of 120/50 millimeters of mercury (mmHg). She had no past medical or surgical history. This was her first pregnancy. Review of systems was noted to be negative. She was noted to have right costovertebral angle (CVA) tenderness on exam and tenderness to deep palpation in the mid-right abdomen. She had no guarding or rebound. The patient had reassuring Category I fetal heart rate tracing. The plan was for management of abdominal pain in pregnancy. The plan was made for monitoring, cervical length, fetal fibronectin (FFN) testing, labs and a full abdominal ultrasound.

A general surgery consult was also ordered. The patient was given intravenous (IV) Dilaudid, and the pain improved. Surgery recommended a magnetic resonance imaging (MRI) for the evaluation of her abdomen. They felt that this may be renal colic. Straining urine was planned. She underwent an ultrasound with normal exams of the abdomen and there were noted gallstones. The common bile duct was normal and there was right sided hydronephrosis noted. Labs were reassuring without evidence of a white count. Lipase and amylase were also normal. Renal function was also normal. An MRI was also completed and noted the appendix to be normal. The gallbladder had stones but there was no evidence of cholelithiasis. There was right sided hydronephrosis with perinephric edema to support possible pyelonephritis. There was no surgical intervention indicated. Urology also consulted on the patient. They recommended straining urine. There was no need for surgical intervention per their consultation. The patient was started on Ceftriaxone for coverage of the possible urinary tract infection. Pain improved and she remained afebrile. The patient was discharged to home on the following date.

At issue is the medical necessity for the inpatient stay. I uphold (in whole) the health plan's determination of medical necessity. Based upon a review of the medical records in this case, there would have been no medical necessity for admission to acute inpatient level of care.

In this case, the patient was admitted with right sided pain that was also present as abdominal and back tenderness on exam. Imaging was able to exclude appendicitis and stones. There was perinephric edema to support possible pyelonephritis. The patient remained afebrile with reassuring fetal testing and negative markers for preterm birth. There was no white count or consideration of sepsis as the patient was well. In this case, the patient would not have required admission to acute inpatient level of care. 

In this case, the patient care would meet criteria for an alternate level of care which would have allowed for IV pain medications, imaging with MRI and ultrasound, labs, IV fluid and consultations. There would have been no medical necessity for admission to acute inpatient level of care.