Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is upheld. 

This is the case of a patient status-post umbilical hernia repair who presented to the emergency department (ED) the following day for abdominal pain and emesis. As per the ED note, the patient presented with pain and complaint of emesis x (times) 10. The patient was afebrile with stable vital signs. The patient had abdominal tenderness in the peri umbilical area with guarding and rebound. Bowel sounds were decreased. There was no distension and negative Murphy's sign. The plan was a computed tomography (CT) of the abdomen and labs. CT of the abdomen revealed gallbladder with moderate distension and questionable wall thickening with a 7 x 7 centimeters (cm) subcutaneous fluid and gas collection at the level of the umbilicus with surrounding fatty stranding which could represent simple edema or cellulitis. The patient was admitted for observation to surgery for abdominal pain with serial exams to be done. White blood cell (WBC) count was 9.4, alanine aminotransferase (ALT) was 23, aspartate transferase (AST) was 15, and bilirubin total was 0.4. The patient was given intravenous (IV) antibiotics.

The patient was admitted to general surgery for observation. Exam by surgery revealed ecchymosis at the umbilicus with soft, non-distended, tenderness to palpation diffusely with guarding or rigidity. The plan as per surgery was 23-hour admission, nothing by mouth (NPO), IV fluids, IV ceftriaxone, Flagyl and Vancomycin.

The patient continued to do well in observation.

The patient was discharged having been stable overnight and afebrile. The pain was well controlled and the patient was tolerating diet. The patient was felt to be stable for discharge. There was mild incisional tenderness and small protrusion at umbilicus which was reducible at time of discharge.

Based upon the records it is felt that the full inpatient admission was not justified as this patient could have been managed as noted by the insurer in an ambulatory/observation setting. The patient presented for abdominal pain and as noted was placed for observation. The patient did not have an elevated WBC and did not have any evidence of sepsis. The patient did not need any inpatient admission but rather observation as they had abdominal pain following surgery with obstipation post operation.

According to the guidelines of  Milliman Care Guidelines (MCG) Inpatient and Surgical Care 27th Edition Abdominal Pain, Undiagnosed ORG: M-05 (ISC) admission may be indicated for 1 or more of the following: hemodynamic instability, severe pain requiring acute inpatient management, peritoneal signs, identification of etiology or finding that requires inpatient care (e.g. ["for example"], aortic dissection, bowel perforation, bowel ischemia, visceral organ torsion, intestinal obstruction), evaluation requires patient to not eat or drink for extended period (e.g., more than 24 hours), inability to maintain oral hydration (e.g. needs IV fluid support) that persists after ED and observation care treatment, suspected toxic megacolon, bacteremia, procedure that cannot be performed on ambulatory basis. Thus, in this case the patient did not warrant inpatient admission. In addition, MCG notes that alternatives to admission include: outpatient care in ED, rapid treatment site, urgent care center, or medical office with laboratory and diagnostic testing, outpatient re-evaluation, and pain management. Thus, observation without full inpatient admission was all that was warranted as she was admitted as noted in the progress notes for observation.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably, with sound medical judgment, and in the best interest of the patient. 

The medical necessity for an inpatient hospital admission is not substantiated.