Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Headache; nausea; vomiting; abdominal pain.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female with a history of familial adenomatous polyposis complicated by desmoid tumor, duodenal adenocarcinoma. She was status post colectomy, cholecystectomy with post op fluid collection, hydroureteronephrosis and ureteral stent exchange. The patient presented with left-sided headache associated with diaphoresis, N/V (nausea/vomiting), and RUQ (right upper quadrant) abdominal pain.

The patient's vital signs were as follows: Temperature 99, pulse 79, respiration rate 18 117/71, pulse oximetry 100% RA (room air). CXR (chest x-ray) revealed NAD (no active disease). CT (computed tomography) revealed NAD (no active disease). The patient's exam revealed RUQ (right upper quadrant) tenderness to palpation. The patient's labs were as follows: WBC (white blood count) 6.4, H/H (hemoglobin/hematocrit) 10/6/33.7, Plt (platelets) 307, Na (sodium) 18, K (potassium) 3.9, BUN/Cr (blood urea nitrogen) 9/.7. LFTs (liver function tests) were within normal limits. U/A (urinalysis) revealed +nitrite, WBC (white blood cells), few bacteria.

The patient was treated with IV (intravenous) anti-emetics, opioids, and antibiotics. The patient was admitted. Plan of care included IV (intravenous) antibiotics x 1 dose, IV (intravenous) dilaudid and IV (intravenous) reglan.

The patient's vital signs were stable, and the patient was afebrile. Her abdominal pain had improved. She had diarrhea. She was changing to PO (oral) regimen. ANC (absolute neutrophil count) was trended, and the patient had serial abdominal exams. No active infection was noted. The plan was to discontinue IV (intravenous) antibiotics, continue IV (intravenous) opioids PRN (as needed). Oral PPI (proton pump inhibitor) was started.

The patient's vital signs were stable, and the patient was afebrile. Her pain improved with Zofran and dilaudid. No evidence of infection was noted. The plan was to discontinue antibiotics and IVF (intravenous fluids). She was cleared for discharge.

No, the Emergent hospital admission was not medically necessary.

Medically necessary services are those which are: safe, effective, generally accepted national standard of medical practice, not provided primarily for convenience of the patient or the practitioner, the least intensive and/or most appropriate alternatives among diagnostic and treatment option.

The requested inpatient admission was not medically necessary, because it was not in accordance with generally accepted national standard of medical practice for this patient's scenario.

This patient with a history of abdominal surgeries was admitted after presenting with subjective fever and abdominal pain.  The patient was hemodynamically stable and afebrile.  There were no acute changes on CT (computed tomography).  The patient did not have severe electrolyte abnormalities.  No infection was identified.  There was no acute condition identified that required an acute inpatient level of care.  Documentation does not support the patient's inability to tolerate PO (by mouth).  The intervention provided did not require an acute inpatient level of care.  The patient had not failed a lesser level of care.  Inpatient admission was not medically necessary.