Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal pain; Aortitis
Issue under review: Inpatient admission

Determination:
The Inpatient admission was medically necessary.

The patient has a history of asthma, COPD, hepatitis C, recent coronary stent placement, and aortic aneurysm. She presented to the emergency department for evaluation of nausea, vomiting, diarrhea, and right sided abdominal and flank pain for the prior two days. She had been seen for similar symptoms on a previous day, and symptomatic therapy provided only partial relief of her symptoms. 

The patient was noted to be agitated. She had bilateral tenderness to palpation of the lower back as well as diffuse abdominal tenderness. She had old-appearing periumbilical ecchymosis on her abdomen. She was hypertensive. Evidently due to agitation, she initially assaulted the RN that tried to place her IV line. 

The ED physician ordered testing including labs, EKG (electrocardiogram), and CT angiogram of the abdomen and pelvis. The patient was placed on an NPO (nothing by mouth) diet. Labs were significant for a leukocytosis and an anemia. Her CT angiogram results showed induration and thickening of the abdominal aortic wall, concerning for aortitis. 

Vascular surgery consultation was obtained. The consultant advised IV antibiotics and monitoring in the step down unit because of concern for possible aortic rupture. The patient was treated with intravenous vancomycin and admitted to the step-down unit. 

The treatment plan consisted of IV antibiotics, ID consultation, IV morphine for pain management, serial labs and bloodwork, GI (gastrointestinal) and DVT (deep venous thrombosis) prophylaxis, management of her chronic medical conditions, and close step-down level monitoring of the patient's signs and symptoms. She required IV pain medications during her stay.

The patient's pain began to resolve, and after a period of monitoring and did not recur. The surgical team determined that her symptoms were unlikely to be related to a progressive aortic process. She was deemed to be stable for outpatient management, although she did continue to require antibiotics for her aortitis. She was switched to oral doxycycline. The patient was discharged home with prescriptions and instructions to follow-up in accordance with her aftercare plan. 

The patient's providers had legitimate reason to be concerned about aortitis, because (1) she had subacute, severe abdominal pain; (2) she had an elevated WBC count; (3) she had a known AAA (Abdominal Aortic Aneurysm); (4) she had a recent cardiac catheterization, which can sometimes cause infectious seeding of the aorta; and (5) her CT showed aortic abnormalities including thickening and stranding. In this clinical scenario, inpatient admission was medically necessary. Other reasons for inpatient admission included pain severe enough to require intravenous narcotic therapy and need for intravenous antibiotics.

Under Milliman criteria [1], inpatient admission is medically necessary for patients who have any of the following: (1) severe pain requiring acute inpatient management; (2) vascular disease condition for which emergency and observation care have failed or are not considered appropriate; (3) a condition that requires the patient not eat or drink for an extended period; and (4) identification of a finding that requires inpatient care (e.g. aortic dissection). The patient met all four of these criteria (note that aortitis is similar in gravity and risk to aortic dissection). Therefore, the patient required inpatient admission under Milliman criteria.