Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

 
This is the case of an adult who as per the triage note was post cholecystectomy and now complained of pain around the surgical site. She denied fever or chills. She has a history of diabetes and right below the knee amputation. The patient was afebrile. As per the emergency department (ED) provider note the patient has a history of congestive heart failure (CHF), diabetes, hypertension (HTN), obesity and opioid abuse who presented with left sided abdominal pain for 1 month. She stated she had a cholecystectomy 1 month ago and she had 2 stents on the right side that were supposed to be removed yesterday but she was unable to make the appointment as she did not have transportation. On exam she had a soft but tender abdomen in the left upper and lower quadrant. The note indicated the case was discussed with surgery and no surgical intervention was needed at this time. They recommended a Gastroenterology (GI) consult for stent removal. The case was discussed with GI who recommended to admit to medicine and that they would be consulted for stent removal. The principal diagnosis was abdominal pain. The white blood cell count (WBC) was 9.26 with a serum glucose of 324, total bilirubin 0.1, alkaline phosphatase 536, aspartate aminotransferase (AST) 59, and an alanine transaminase (ALT) of 48. A computed tomography (CT) of the abdomen revealed a common bile duct stent in place with pneumobilia reflecting stent patency and moderate to large stool burden through the entire colon reflective of constipation. There was no evidence of colitis. 

Her pain was 10 out of 10. She had a serum glucose of 324, alkaline phosphatase of 536 and an AST of 59. The CT of the abdomen revealed a moderate to large stool burden throughout the colon. The patient was given intravenous (IV) Zofran and IV morphine. According to the history she was admitted for ERCP (endoscopic retrograde cholangiopancreatogram). The severe pain was managed by IV (intravenous) push of Morphine as needed. GI service was consulted for stent removal. The patient had an American Society of Anesthesiologists (ASA) score of 3. She underwent an ERCP with biliary stent removal and balloon sweep of the small stones and sludge with excellent drainage. She was cleared for discharge. A review of the records showed that the patient could have been managed in a lower level of care where the patient could have been treated for symptoms and observed for response to treatment.

In addition according to MCG (Milliman Care Guidelines) Inpatient and Surgical Care 26th 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 a finding that requires inpatient care (aortic dissection, bowel perforation, bowel ischemia, visceral organ torsion; intestinal obstruction); Evaluation requires the patient to not eat or drink for an extended period (more than 24 hours); the inability to maintain oral hydration (IV fluid support) that persists after emergency department and observation care treatment; Suspected toxic megacolon; Bacteremia; and the procedure cannot be performed on ambulatory basis. Thus, in this case the patient did not warrant inpatient admission as her pain was not significant- she was only presenting for stent removal via ERCP which is an ambulatory procedure.

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

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