Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient hospital admission

The insurer denied the inpatient hospital admission.  The health plan's determination is upheld.

The patient is a female with a history of asthma and migraines, who presented to the emergency room (ER) with complaints of right lower quadrant (RLQ) abdominal pain. She stated she has been having abdominal pain for 4 months and despite treatments and the work up by her primary care physician (PCP), the pain persists. Over the previous 4 days, the pain had been getting progressively worse. She had one episode of diarrhea, no bleeding and has a history of hysterectomy. The patient had no relief with Ibuprofen. On exam, the patient had normal vital signs and tenderness in her RLQ. The rest of the patient's exam was unremarkable. Her labs showed the following normal tests: complete blood count (CBC), comprehensive metabolic panel (CMP), lactic acid (LA) and urinalysis (UA). Her chest x-ray showed bibasilar atelectasis and scarring. The computed tomography (CT) of her abdomen and pelvis showed no perinephric inflammatory changes, a 1 millimeter (mm) calcification in the right pelvis which may represent a vascular calcification or a punctate non-obstructing right distal ureteral stone and a normal appendix. The patient has a heterogenous cervix with multiple low-density regions possibly related to nabothian cysts. There was a recommendation for a transabdominal and transvaginal pelvic ultrasound (US). She received Toradol 15 milligrams (mg), Morphine 4 mg twice, fluids, Zofran and was subsequently admitted for intractable abdominal pain.

The patient's pelvic US showed multiple cystic appearing lesions at the level of the cervix, the largest was 1.5 centimeter (cm), which was suggestive of multiple nabothian cysts.

She had no issues overnight. The patient was seen the following day. The patient had complaints of pain. The patient complained of some nausea and bloating, as well as some numbness in the soles of her feet, which had been present for a few months. She had a stable exam and mild abdominal tenderness. She was seen and examined by the gynecologist. A determination was made that the patient's pain was not caused by endometriosis. A diagnosis of chronic pelvic pain and dyspareunia could be associated to pelvic floor muscle myalgia. The recommended treatment was Tylenol, Toradol or Oxycodone for severe pain, pelvic floor physical therapy (PT) and outpatient follow up with her gynecologist.

The health plan, in its determination of medical necessity, acted reasonably, with sound medical judgment and in the best interest of the patient. The patient presented with complaints of abdominal pain that had been present for over 4 months and stating that she had been treated by her PCP without relief. In the ER, she had normal vital signs, labs, CT scan, did not give history of vomiting and did not have bloody diarrhea. The patient had cysts on her ovary that were not significantly large nor had any evidence of rupture. She did not require any acute surgical nor gynecological intervention.

As a result, there is no clinical evidence to show why she could not have been treated in the ER or placed in an alternate level of care with subsequent follow up with either her PCP or gynecologist.

The requested health service and treatment of an inpatient hospital admission was not medically necessary for the patient.