Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain. 
Treatment: Hospital Admission. 

The insurer denied coverage for hospital admission. 

The denial is upheld. 

According to the documentation submitted, this is an adult female who presented to the ED (emergency department) with complaint of abdominal pain. She was afebrile. She has had epigastric pain for 2 days with nausea that just started tonight. She has been constipated. Her last bowel movement (BM) was a few hours ago. As per the emergency department (ED) provider note, she has had generalized abdominal pain for the past few days. She denied fever or chills. Her abdomen was soft, non-distended with tender to palpation in the epigastric region. There was no rebound or guarding. White Blood Cell (WBC) was 12.2. Computed tomography (CT) of the abdomen revealed enlarged appendix with adjacent fat stranding compatible with acute appendicitis. There was wall thickening of the terminal ileum which was similar to the prior exam and compatible with terminal ileitis. Correlation to Crohn's disease was suggested. General surgery consult was requested. 

The test results showed no blockage in the belly. The patient was treated with medicines (for possible infection) and was treated with specialist care (surgery and gastroenterology consults). The patient was watched. There are no notes that the patient had an unstable heart rate or blood pressure after treatment. There are no notes that the patient did not get better and needed treatment (for longer than observation level of care (48 hours)). There are notes that the patient had a blockage in the bowel or had widening of the large bowel (megacolon). There are no notes that the patient had low fluid in the body or that the patient had ongoing vomiting and needed continuous fluids by vein after observation care. There are no notes that the patient needed surgery right away and that this surgery is usually not done as a same day (ambulatory) surgery. There are no notes that the patient had pain that did not get better and needed treatment (for longer than observation level of care (48 hours)). The decision was based on Milliman Care Guidelines (MCG) 25th edition abdominal pain, undiagnosed ORG: M-05 (ISC). 

The patient was undergoing work up for Crohn's disease with planned endoscopy and colonoscopy (interrupted by finding of pregnancy) after an imaging study revealed terminal ileitis. Surgery was consulted in setting of acute appendicitis, terminal ileitis with a recommendation for surgical intervention. Gastrointestinal (GI) consultation was obtained. In the setting of termina ileitis, the plan to intervene surgically was debated. She remained on antibiotics with serial abdominal exams. As per GI consultation, symptoms were suspicious for Crohn's given persistence of terminal ileitis, but they cannot exclude acute appendicitis given imaging findings. The recommendation was to continue intravenous (IV) antibiotic therapy, clear liquid diet. Colonoscopy was advised but not urgent with recommendation to wait until inflammation resolved to minimize complications. Inpatient criteria was met based on MCG. General admission criteria with admission indicated for continuous IV fluids, IV antibiotics, imaging, serial exam. The enclosed medical record clearly indicated the need for acute medical management. 

According to MCG General Recovery Guidelines Gastroenterology, this patient did not have justification for inpatient admission as she could have been managed in an observation setting as she required observation as it was not clear that she had appendicitis but rather terminal ileitis. With treatment of IV antibiotics, she improved and was discharged.  The patient could have been managed with an observation setting with a short course of IV antibiotics followed by oral antibiotics and discharge. 

The health plan acted reasonably with sound medical judgment in the best interest of the patient. The insurer's denial of coverage for the hospital admission is upheld. Medical Necessity is not substantiated.