Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Swallowed a Foreign Object
Treatment: Inpatient Stay
The insurer denied the inpatient stay.
The health plan's determination is upheld.

The patient is a female with a medical history of irritable bowel syndrome, asthma, hypertension, gastroesophageal reflux disease (GERD), chronic abdominal pain and colitis. She presented to the emergency department with an accidental foreign body ingestion and severe right upper quadrant abdominal pain for 12 hours. She had recently undergone an esophagogastroduodenoscopy and a colonoscopy. A missing wire from her braces was noted. Her vital signs were unremarkable. Her physical examination was notable for a soft abdomen with generalized tenderness. Her laboratory studies showed an elevated white blood cell count of 13.9 kilo per microliter (K/uL).

The x-ray of the abdomen showed a possible linear ingested foreign body such as fishbone measuring 2.4 centimeter (cm) in the mid-abdomen. A computed tomography scan of the abdomen and pelvis showed a radiopaque in the small bowel loops in the central abdomen slightly to the right of midline, with no evidence of obstruction or pneumoperitoneum. She was treated with intravenous Ondansetron, Pantoprazole, Metoclopramide, Diphenhydramine, Ketorolac, Dilaudid, and fluids. She was made nothing by mouth (nil per os). A surgery consultation assessed her to have a progressing foreign body without peritonitis, and since it had progressed to the small bowel, it may pass without issue. The recommendation was for mechanical bowel preparation, and a free air series the next day to reevaluate the location. No surgical intervention was warranted, but emergent exploration would be warranted if the patient's pain worsened, her abdominal examination changed, or if she became hemodynamically unstable.

The x-ray of the abdomen showed that the linear foreign body in the bowel migrated into what appears to be the terminal ileum. The recommendation was for a repeat x-ray of the abdomen, and if the linear foreign body had not moved in a week, a repeat computed tomography scan of the abdomen and pelvis would be needed to assess for inflammatory changes. She had moderate abdominal pain, positive bowel function, and denied nausea, vomiting, fever, and chills. 

The inpatient stay was not medically necessary and is not supported in this case. The most recent available American Society for Gastrointestinal Endoscopy (ASGE) guidelines for the management of foreign body recommend emergent endoscopic removal only for sharp-pointed objects in the esophagus, stomach, or duodenum. For sharp objects, the guidelines state that once the sharp object has passed the duodenum, it may be followed with daily radiographs to document its passage, and surgical intervention should be considered for objects that fail to progress after 3 days [1]. 

Surgical intervention was considered in this case, and deemed unnecessary soon after presentation [2]. There was no bowel perforation, peritonitis, sepsis, hemodynamic instability, or bowel obstruction [3-7]. The patient had appropriate conservative monitoring and serial imaging, but did not develop any instability to warrant intervention [1-7]. The care provided, including monitoring, imaging, laxative therapy, and specialist consultations, could have been performed at alternate level of care, without the inpatient level of care.

According to the InterQual Acute Adult General Trauma criteria, the observation level of care is supported for a foreign body with assessment and monitoring at least every 4 hours and if it is unable to be extracted in the emergency department. The acute level of care is not supported due to lack of surgery planned within 24 hours, bleeding, liver injury, spleen injury, cardiovascular disease, eye disease, musculoskeletal disease, neurological disease, respiratory disease, or skin disease.