Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal 
Treatment: Inpatient Hospital 

The insurer denied the inpatient hospital admission. The denial is upheld in whole. 

The patient is a female with a past medical history significant for C-section and eye surgery who presented to the emergency department with complaints of nausea, vomiting, abdominal pain, diarrhea, also subjective fever, and chills, which started approximately one week before the presentation. The review of systems was positive for brown vaginal discharge. Her symptoms were aggravated by movement and meals. Rest and heat alleviated the symptoms. 

When seen in the emergency department, the patient was afebrile. Blood pressure was 115/69, pulse rate was 83 beats per minute (bpm), respiratory rate was 14, and oxygen saturation was 98% on room air. The patient appeared well developed. The head, eyes, ears, nose, throat (HEENT) exam was within normal limits. The patient was tachycardic, without murmurs, rubs, or gallops. She had a normal pulmonary exam. 

The abdomen was soft with good bowel sounds in all four quadrants, there was mild tenderness throughout, with more tenderness across the lower quadrants. There was no guarding or rebound. The rest of the exam was unremarkable. 

The laboratory evaluation revealed that white blood cell count was 18.4, hemoglobin was 11.3, hematocrit was 36.3, platelets were 336. Sodium was 140, potassium was 3.8, chloride was 107, bicarbonate was 24, blood urea nitrogen (BUN) was 8, and creatinine was 0.7. Computed tomography (CT) scan of the abdomen and pelvis demonstrated no acute findings in abdomen or pelvis. Normal appendix. The patient underwent pelvic ultrasound, which was reported as an essentially unremarkable study. 
In the hospital, the patient was seen by the general surgery service and was diagnosed with abdominal pain, nausea, loose stools, and leukocytosis. The surgeon recommended admission to hospitalist service for treatment of possible enteritis with intravenous fluids, pain, and nausea medications. 

The patient also received treatment with intravenous antibiotics. Her symptoms significantly improved, and leukocytosis resolved. During the stay, the patient remained afebrile and hemodynamically stable. She was switched to oral antibiotics and discharged home. The subject under review is the medical necessity for the inpatient admission. 

The health plan's determination is upheld in whole. 

This patient presented to the hospital with symptoms of acute gastroenteritis. Neither the physical exam nor the results of the laboratory studies and diagnostic tests revealed the presence of a serious medical problem. The only exclusion was leukocytosis, which is common in cases of acute gastroenteritis. 

At the same time, there was no evidence of significant dehydration, electrolyte abnormalities, severely diminished oral intake, or a need for any surgical intervention. 
Overall, she remained in stable clinical condition, there were no signs of hemodynamic instability, and she tolerated her diet. The patient's condition started to improve within a short period of time, and she was appropriately switched to oral antibiotics and discharged home. 

According to the Merck Manual Professional Version online, "Supportive treatment is all that is needed for most patients. Bed rest with convenient access to a toilet or bedpan is desirable. Oral glucose-electrolyte solutions, broth, or bouillon may prevent dehydration or treat mild dehydration. Even if vomiting, the patient should take frequent small sips of such fluids; vomiting may abate with volume replacement." Taking into consideration all these facts, neither the severity of the patient's condition nor the complexity of services provided rose to the level of acute inpatient care. The patient's care could have been appropriately managed at a lower level of care status.