Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld.

The patient is a female whose inpatient admission is under review. She has a past medical history of depression, hypertension, and asthma.

The patient went to the emergency room complaining of abdominal pain and constipation. A CT (computed tomography) scan showed no acute inflammatory condition. The emergency room physician stated the patient was "well appearing" but the pain had not resolved. She was admitted to acute care for further management for intractable abdominal pain.

The patient's initial blood pressure was 149/93, temperature normal, pulse 73, oxygenation one hundred percent, abdomen with normal bowel sounds, tenderness but no peritoneal signs. The CT (computed tomography) was consistent with constipation. The BUN (blood urea nitrogen) was 10, creatinine normal, electrolytes normal, ALT (alanine aminotransferase) 45, bilirubin normal, AST (aspartate aminotransferase) 54. The EKG (electrocardiogram) had no ischemic changes. HIV (human immunodeficiency virus) and COVID 19 were negative. WBC (white blood count) was normal at 9.3.

On day two, the patient's temperature remains normal, WBC (white blood count) normal. The patient was able to ambulate, and mental status was normal. No need for surgery was noted. The patient had no distress. The plan was to continue bowel regimen, fiber supplements, MiraLAX. General surgery documented no surgical abdomen.

On day three, the patient's electrolytes were normal, WBC (white blood count) 10.0. The plan was to continue constipation regimen.

Day four, the patient complained of pain and discomfort. There were no events overnight. The plan was to continue bowel regimen. "Strange for constipation to cause this much pain" is noted.

Day five, the GI (gastroenterology) consult documented laxative treatment, no nausea, tolerating her meals, ongoing complaints of pain. There was mild tenderness in the abdomen, hemoglobin stable. The patient was getting morphine for pain. A request for advancing her diet to solids is noted.

Day six,  the patient's lower abdominal symptoms were gone, but she was still complaining of epigastric pain. She had no chest pain. She was eating solid food. She had no fever. She had a bowel movement the day before with improvement in pain.

Day seven, a discharge summary was dictated. The patient was tolerating the diet, and she was hemodynamically stable. Her abdomen only had mild tenderness with no rebound, no distention. She was able to ambulate to and from the bathroom without difficulty, but reporting no bowel movement.

Day eight, the patient was stable, tolerating sandwiches and juice. The plan was to continue IV (intravenous) fluid. She patient agreed to have an enema. She had no fever. Her WBC (white blood count) was normal. Her hemoglobin was 12.3.

Day nine, a plain x-ray of the abdomen was normal. The plan was to continue pain management and laxatives, bisacodyl, fiber, and consider EGD (esophagogastroduodenoscopy).

Day ten, the patient was tolerating the diet. Her abdominal pain improved, and she was discharged home. She refused EGD (esophagogastroduodenoscopy) and went home.

No, the Inpatient admission was not medically necessary.
The entire hospital stay  was not medically necessary at the acute care level. As early in the emergency room there was no fever, no hemodynamic instability, no bleeding, no anemia, no electrolyte disorder, no toxic state, no peritoneal signs, no need for surgery, no need for immediate colonoscopy. The patient had a report of constipation and history of chronic abdominal pains. Pain management does not require acute care and can be accomplished at a lower level of care. The main therapy were laxatives and pain medicines, which do not require acute care. Throughout the entire stay, the patient's temperature and blood pressure remained stable, the hemoglobin remained stable, there was no observed vomiting, and no evolution of abdominal findings. The imaging showed no acute inflammatory condition, no obstruction. Constipation can be treated at a lower level of care and does not require acute care management. Once the surgeons documented no requirement for surgery, there was no plan for immediate endoscopy, no bleeding, no toxic state, no bowel obstruction, no persistent vomiting, no bleeding or drop in hemoglobin, the patient did not require acute care for the entire time.

This patient did not require acute care for pain management and treatment of constipation. These conditions are often treated in the outpatient setting and do not require acute hospital level of care

Serur described, "Lower gastrointestinal hemorrhage remains a common cause of hospitalization, with significant health care costs. Initial management should include aggressive resuscitation followed by localization of bleeding with nuclear scintigraphy, colonoscopy, or computed tomography (CT) angiography. If bleeding does not resolve spontaneously, expeditious intervention with minimally invasive endoscopic or angiographic methods is necessary with surgical intervention as a last resort. Currently, there are several endoscopic hemostatic techniques that are used, including injection of epinephrine, bipolar/monopolar electrocoagulation, argon plasma coagulation, application of clips, and band ligation. Alternative treatment options under development include the application of various hemostatic agents and advanced over-the-scope clip (OTSC) application devices."

No bleeding requiring acute care was documented in this case.

In this case, no unremitting total obstruction, bowel perforation, severe ischemia, clinical deterioration with medical therapy, leukocytosis, fever, dehydration, electrolyte abnormalities, was described that required acute care.

Yao described, "Good short-term outcomes and feasible long-term outcomes were achieved with a laparoscopic approach to treating acute SBO [small bowel obstruction]. It was a safe and effective method, especially in patients with isolated bands, simple enteral angulation, and foreign body or tumor, while dense and matted adhesions were still challenging."

No surgery requiring acute care was described in this case.

Kang described uncomplicated surgery: "Single-port laparoscopic surgery (SPLS) is an alternative, minimally invasive surgical approach for managing appendicitis. The aim of this randomized trial was to evaluate the safety and efficacy of SPLS [single-port laparoscopic surgery] in uncomplicated appendicitis. This randomized trial indicates that, compared to MPLS (multiport laparoscopic surgery), SPLS [single-port laparoscopic surgery] does not increase the rate of perioperative or postoperative complications in uncomplicated appendicitis."

No appendicitis or acute inflammatory condition was documented in this case that required acute care.