Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lower abdominal pain.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female who presented to the emergency room with complaints of bilateral lower quadrant pain, left greater than right, and nausea. Her past medical and surgical histories included Crohn's Disease and hysterectomy. On admission her vital signs were normal, and she was afebrile. She was not in acute distress. Bilateral mild to moderate lower quadrant tenderness was reported, and a pelvic examination was normal and nontender. A complete blood count (CBC) was normal. A computed tomography (CT) scan revealed a 23 millimeter (mm) left ovarian cyst. A pelvic ultrasound confirmed the finding. Intravenous (IV) fluids, morphine and Toradol were given. The patient was observed for six hours and continued to complain of abdominal pain. 

The patient was admitted to the inpatient service for documented indications of pain control and antiemetics. A gynecologic consult was performed. Intramuscular (IM) medroxyprogesterone was administered and outpatient follow-up recommended. She was discharged on gabapentin and naproxen.

No, the proposed treatment was not medically necessary.

The proposed treatment is not medically necessary. The medical records and medical literature were thoroughly reviewed. The patient had a diagnosis of lower quadrant abdominal/pelvic pain. Her condition was stable with no evidence of hemodynamic instability and continued stable throughout her admission. There was no evidence of infection including a normal CBC and no fever. A pelvic examination was performed and was normal. The admitting physician reported no suggestion of inflammatory bowel disease. Appendicitis or colonic disease was not confirmed and there was no evidence of significant pelvic infection, hemorrhage or ovarian torsion which could have indicated gynecologic inpatient admission. Depot medroxyprogesterone, a medication typically prescribed and administered in an outpatient setting with a therapeutic effect that takes days, and not an acute inpatient treatment, was administered. Afebrile patients with the diagnosis of pelvic pain having stable vital signs may, within the standard of care, remain in the emergency room or can be transferred to an intermediate care setting for the purpose of observation and pain management. Patients with this condition may improve with time and pain management. Inpatient admission therefore may not be medically necessary, and patients can be typically be discharged from the emergency room or intermediate care unit when appropriate. 

This patient was appropriately observed and given pain medication in the emergency room for a short time period, and her condition remained stable. Suspicion of endometriosis based on the pelvic ultrasound was documented as part of the differential diagnosis by the admitting physician. The gynecologist prescribed depot medroxyprogesterone in response. Therefore, the inpatient admission was not indicated. Therefore, according to the medical record there was no indication for inpatient admission. The patient could have been cared for at a lower level of care. The inpatient admission was not medically necessary.