Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Constipation. 

Treatment: Inpatient hospital admission.

The insurer denied coverage for inpatient hospital admission.

The denial is upheld. 

This male child patient with a benign past medical history presented to the Emergency Department (ED) for evaluation of 1 day of sharp, 10 out of 10, left lower quadrant abdominal pain in the setting of no bowel movement for 1 day. The patient's pain was associated with an episode of vomiting. There was no associated dysuria, chills, weight loss or bleeding. The patient's abdomen exam was notable for normal bowel sounds, soft with mild tenderness to palpation in the right lower abdominal quadrant. The patient's pain appeared to wax and wane. There was no distension, rebound, consistent guarding, and no masses or organomegaly detected. Imaging included an abdominal x-ray that showed no obstruction but stool throughout the colon. The patient received ibuprofen, intravenous (IV) Tylenol with Zofran, and a Fleet's enema. An abdominal computed tomography (CT) scan that showed stool throughout the colon. A second enema was unsuccessfully attempted. The patient was given a glycerin suppository. The patient was seen by pediatric surgery that recommended admission, nothing-by-mouth (NPO) status, IV hydration, serial abdominal exams, laxatives, trending white blood cell count and possible repeat films. A single tap water enema was given followed by flatus and liquid brown output and complete resolution of symptoms. The patient was discharged the same day as admission (within 6 hours).
 
This patient appeared to have recent onset of constipation leading to intermittent crampy abdominal discomfort without significant dehydration and non-bloody vomiting. The patient was able to tolerate oral medications and contrast prior to admission and never vomited once he resumed his diet. Imaging ruled out acute conditions. According to a review of the causes of abdominal pain in children and adolescents by UpToDate , the reasons to admit such an individual would include signs of significant dehydration poorly responsive to IV hydration in the ED, hemodynamic instability, significant electrolyte imbalance, demonstrated oral hydration intolerance, poorly controlled pain, concerning exam findings for a surgical process or findings consistent with significant blood loss or bowel obstruction. This patient was admitted with constipation for pain control but required no additional pain medications after transfer from the ED. 

Constipation can follow a social change such as toilet training, starting school, changing the diet, or taking a trip. The child frequently does not know that his or her pattern of stooling has become abnormal, and the parent is not aware of a change. Nausea can accompany constipation, but other symptoms are rare. Examination may show distention, a mass in the left lower quadrant or low mid-abdomen, and mild tenderness. The rectal examination usually demonstrates a full rectal vault. Guarding is not typical. An abdominal x-ray should show a full rectal vault and fecal loading, but signs of obstruction are absent. 

As per Ross and LeLeiko (2010), this patient did not present with an acute abdomen that required surgical intervention. The diagnosis of constipation was known but the treatment in the ED was only one enema and one suppository without effect. Once admitted, a single tap water enema led to complete resolution of symptoms. The patient's pain was clearly intermittent and did not persist after admission and treatment of his constipation. The short duration of this patient's admission without intervention other than one enema demonstrates that this patient's care met criteria for observation and not for acute inpatient care. 

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

Based on the above, the medical necessity for inpatient hospital admission is not substantiated. The insurer's denial should be upheld.