Appeal type: Medical necessity
Decision: Upheld

Issue: Medical necessity 
Diagnosis: Digestive System/ Gastrointestinal
Treatment: Inpatient Hospital stay
The insurer denied inpatient Hospital stay
The health plan determination is upheld in whole.


The inpatient stay was not medically necessary.

The patient has a medical history of laparoscopic adjustable gastric band placement in past complicated by small incisional hernia, two prior small bowel obstructions which responded to nil per os status and intravenous fluids, and hypothyroidism. Patient presented to the emergency department with one day of diffuse nonradiating, constant, moderate-intensity abdominal pain with no provoking or palliating factors;  also had nausea and vomiting. Patient had nausea and vomiting in the emergency department and had a normal bowel movement the day prior. Vital signs were unremarkable. Physical examination was notable for soft, nondistended abdomen with moderate generalized tenderness, no rebound tenderness or guarding, negative Murphy sign, and normal bowel sounds. Labs showed elevated glucose of 142 mg/dL and elevated calcium of 10.9 mg/dL. Computed tomography scan of the abdomen and pelvis showed several disproportionately dilated distal small bowel loops in the lower abdomen and right lower quadrant, without definite single transition point; findings were favored to represent partial small bowel obstruction most likely due to adhesions; there was no discrete enhancing mass, pneumatosis, abscess, or pneumoperitoneum. Patient was treated with intravenous fluids, ondansetron, fentanyl, morphine, ketorolac, and famotidine,  was made nil per os. Surgery consultation on  noted 3/10 right lower quadrant abdominal pain and control of vomiting with ondansetron; physical examination was notable for soft abdomen with hypoactive bowel sounds, mild abdominal distention, and moderate tenderness and palpable fullness in the right lower quadrant, ventral hernia in the right mid-abdomen; the recommendation was bowel rest with nil per os and intravenous fluids, serial abdominal exams, treatment ambulation, and repeat labs and abdominal imaging the next morning. Patient noted feeling much better, with improvement in abdominal pain and a bowel movement, and  was tolerating oral intake, and noted some cramping pain and a headache. Complete blood count and basic metabolic panel were unremarkable. X-ray of the abdomen showed gastric band in satisfactory position, gas and stool in the colon, no small bowel dilation or obstruction, and no significant air-fluid levels. Patient was started on a soft diet and discharged. 

The patient presented with abdominal pain, nausea, and vomiting, and imaging consistent with partial small bowel obstruction. However, there was a lack of peritonitis, abscess, perforation, fistula, and other complications; the patient had resolution within a day, without nasogastric tube placement. The standard of care for uncomplicated partial small bowel obstruction, including intravenous fluids, serial abdominal exams, nil per os status with gradual advancement of diet, and monitoring of labs was performed, and all could have been performed without the inpatient level of care [1-5]. For these reasons, the inpatient level of care is not supported based on the provided information.
The patient did not meet the MCG Intestinal Obstruction RRG for an inpatient level of care.