Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld.

This patient is a female (body mass index [BMI] 23.8 kilograms per meter squares [kg/m2]) who presented to the emergency department with the complaint of abdominal pain of three-weeks duration associated with nausea, hematemesis, and diarrhea with episodic melanotic stool. She also has complaint of solid food dysphagia of three months duration.  Comorbid health conditions included a history of roux en Y gastric bypass many years prior with a subsequent revision for bowel obstruction and perforation.  She also has a history of alcohol abuse, coronary artery disease and prior myocardial infarction.  She is also reported to smoke cigarettes.

Vital signs at the time of presentation were normal.  Examination revealed a tender abdomen in the right lower quadrant. The white blood cell (WBC) count was low at 2.9 thousand (K).  Hemoglobin was low at 9.3.  Serum transaminases were elevated with normal bilirubin.  Abdominal computed tomography (CT) showed anatomic changes of prior gastric bypass, an increase in the proximal small bowel caliber and findings of possible mesenteric volvulus with swirling of the mesentery in the left mid to lower abdomen (different from a prior study).  Surgical and gastroenterology consultation was obtained.  The patient was admitted to the hospital.

The patient was initially treated with nothing by mouth (NPO) status, intravenous (IV) fluid and follow up lab data.  On day two, the abdominal pain was improved and the patient had no episodes of emesis.  Upper endoscopy was planned by gastroenterology.  The patient's diet was advanced to soft foods and on day three, the patient wanted to go home.  Vital signs were normal (heart rate was 79 beats per minute).  The pancytopenia and transaminitis was attributed to chronic alcohol abuse.  She was discharged from the hospital.  Upper endoscopy was advised to be performed post discharge.

The health plan rationale for denial of inpatient care was based on Milliman Care Guidelines (MCG) Criteria 24th edition - Medical, Gastroenterology.

No, the proposed treatment was not medically necessary.
In this case, inpatient care was not medically necessary.  The care and treatment provided during this time could have been rendered with an observation level of care and did not require an inpatient designation.  This lower level of care would have provided for surgical and gastroenterology assessment, follow up, labs, and arrangements for outpatient follow up for upper endoscopy.

This patient presented with abdominal pain.  Her evaluation with examination, lab data, and computed tomography (CT) scan identified chronic lab abnormalities and computed tomography abnormalities, as noted above.  The surgery notes indicate that no surgical intervention was planned.  The patient was treated with follow up labs and initially with nothing by mouth (NPO) status with clinical improvement overnight.  She did not require acute surgical intervention.  She was clinically stable during the period of monitoring and was able to be discharged on day three with arrangements for outpatient follow up. 

This patient's clinical needs could have been satisfied with an observational level of care.  This level of care would have provided for clinical assessment and monitoring as was performed.