Appeal type: Medical necessity
Decision: Upheld

This is a patient with a medical history of hypertension. She presented to the emergency department with abdominal pain, bloating, nausea, bitter taste, abnormal smell, weakness, and palpitations starting 1 to 2 weeks prior. She noted improvement with self-induced vomiting. Vital signs were notable for an elevated blood pressure of 185/99 millimeters of mercury (mm Hg). Lab results were unremarkable. A chest x-ray was unremarkable. A computed tomography scan of the brain showed an old infarction of the right caudate, but no acute process. The patient was started on pantoprazole twice daily, Zofran, and Maalox. She had persistent bloating and burning abdominal pain. Lab results showed a lower hemoglobin of 11.5 grams per deciliter (g/dL). An x-ray of the abdomen showed a nonobstructive bowel gas pattern.  A Gastroenterology consultation  suspected gastroesophageal reflux disease, gastritis, or peptic ulcer disease, and recommended esophagogastroduodenoscopy, ultrasound, and pantoprazole. She had persistent bloating and burning abdominal pain. An esophagogastroduodenoscopy  showed a small hiatal hernia, gastritis, and a normal duodenum; biopsies showed mild chronic inactive gastritis without Helicobacter pylori. She was discharged on pantoprazole (40 milligrams (mg) twice daily for two weeks, then 40 mg daily) and Tigan (as needed for nausea) with a plan for Primary Care follow-up in one week. At issue is the medical necessity for an inpatient level of care.
The health plan's determination is upheld. The patient presented with abdominal pain and nausea. This was consistent with inflammation (esophagitis, gastritis, duodenitis, peptic ulcer disease); however, there was no sustained tachycardia or hypotension, gastrointestinal bleeding, acute pancreatitis, gastrointestinal perforation, abscess, fistula, peritonitis, sepsis, or bowel obstruction [1-5]. The patient had an endoscopy with a finding of gastritis three days after presentation, and had close monitoring, which were warranted. However, all of the measures that were undertaken, such as observation, monitoring, labs, endoscopy, proton pump inhibitor therapy, and intravenous fluid administration, could have been performed without an acute inpatient level of care [2-5].
Per the Milliman Care Guidelines for Abdominal Pain, Undiagnosed, the inpatient level of care was not medically necessary, as the patient did not meet the following criteria: surgery needed that cannot be performed on an ambulatory basis, peritoneal signs present (eg, rebound tenderness, rigidity), evaluation requires patient to not eat or drink for extended period (eg, more than 24 hours), hemodynamic instability, severe pain requiring acute inpatient management, identification of etiology or finding that requires inpatient care (eg, aortic dissection, free air, bowel ischemia, visceral organ torsion), signs of intestinal obstruction, suspected toxic megacolon, high fever or infection requiring inpatient admission, severe electrolyte abnormalities requiring inpatient care, inability to maintain oral hydration (eg, needs IV fluid support) that persists after emergency department and observation care treatment, percutaneous or open drainage (eg, abscess, biliary tract) procedures, parenteral nutrition regimen that must be implemented on inpatient basis, other condition, treatment, or monitoring requiring inpatient admission.