Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain

Treatment: Inpatient hospital admission

The insurer denied coverage for an inpatient hospital admission.

The denial is upheld. 

The patient has a history of gastric bypass surgery, gastric perforation, intussusception, and jejunojejunostomy (JJ) staple line with dehiscence and reconstruction. The patient presented to the emergency room (ER) from a skilled nursing facility (SNF) with complaints of abdominal pain. A computed tomography (CT) scan of the abdomen revealed constipation. The white blood cell (WBC) count was within normal limits (WNL). The patient was admitted for care. The patient was kept on nothing by mouth (NPO) and was started on intravenous (IV) fluids. Rectal disimpaction was done. The patient was able to pass stool without difficulty after the procedure. Pain medication was given as needed (PRN). The patient was able to tolerate a regular diet. The patient was discharged after a period of hemodynamic stability. 

According to Gastroenterology MCG (Milliman Care Guidelines) Health: General Recovery Care 25th Edition Clinical Indications for Admission to Inpatient Care, hospital admission is needed for appropriate care of the patient because of one or more of the following:

1) Encopresis or severe fecal impaction and one or more of the following: ambulatory and observation care management [eg (for example), oral medication, enemas] unsuccessful or complication of fecal impaction requiring inpatient treatment (eg, moderate to severe abdominal pain).

The patient did not have an elevated white count or bowel obstruction. The patient had fecal impaction ameliorated by a manual disimpaction. The care could have been rendered in its entirety at a lower level of care for the entirety of the episode of care. Therefore, the inpatient hospital admission was not medically necessary.      

Per Pepe, J., Murphy, M. M., O'Connell, K. P., & Zabbo, C. P. (2017), "Fecal impaction is a common complaint addressed in the emergency department (ED). Serious complications are not often observed, and the problem is commonly resolved quickly with a manual disimpaction. Most patients do not require laboratory evaluation or advanced imaging. [1] Occasionally the search for alternative diagnoses requires diagnostic testing beyond the history and physical exam. Imaging may demonstrate secondary diagnoses related to the physiologic disruption caused by severe retention of fecal material."

In many cases of fecal impaction, manual disimpaction is required. This is a helpful procedure if one can palpate hard stool in the rectal area. The procedure is best done using ample lubrication and gently removing the impacted stool with the index finger. Sometimes, the procedure can be aided with the use of an anoscope and suction. Most patients find immediate relief once fecal disimpaction is performed."

Despite the member's presentation, the care as provided could have been rendered in its entirety at a lower level of care. The patient had fecal impaction, yet she did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for a prolonged NPO status, need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias, or any other indication for an acute admission. As such, the care could have been rendered at a lesser level.

The health plan acted reasonably, with sound medical judgment, and in the best interest of the patient.

The insurer's denial of coverage for the inpatient hospital admission is upheld. Medical necessity is not substantiated.