Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Abdominal pain.
Treatment: Inpatient stay.
The insurer denied the inpatient stay as not medically necessary. The denial was overturned in part.


At the time of admission the patient was  previously healthy,  brought to the emergency department (ED) with three days of vomiting and diarrhea and one day of worsening abdominal pain, decreased oral intake, and dysuria . On arrival,  was afebrile with normal vital signs. Exam was normal except for right lower quadrant tenderness to palpation. Appendix ultrasound was non-diagnostic, pelvic ultrasound was normal, and computed tomography (CT) scan was normal. Labs were normal. Patient received intravenous (IV) fluid and IV morphine initially for pain in the ED, and that was followed by Toradol. An RN documented "good pain relief" with the Toradol, although the ED physician documented "patient still reports 10/10 right lower quadrant (RLQ) abdominal pain, no improvement with IV Toradol or IV acetaminophen. The patient had normal vital signs and was described as being in no distress, well appearing and well nourished. Lips were dry, but mucus membranes were moist and cap refill was less than two seconds. The rest of the exam was normal except for 9/10 right lower quadrant pain to palpation. UA, urine culture, chlamydia and gonorrhea testing were ordered, as was continued IV fluid, IV Toradol, and as needed (prn) Zofran. Gynecology saw the patient in the morning  and documented appeared in no distress and had a soft, nontender abdomen without rebound or guarding. Pediatrics documented a waxing and waning picture--sometimes appearing to be pain free, other times endorsing 9-10/10 right lower quadrant pain, worsening with trying to take po's or be up and about. A number of psychosocial issues were documented, and child life and social services became involved. Patient was discharged improved.
The requested service of inpatient stay was medically necessary for this patient in part. This teen was brought to the ED with three days of nausea, vomiting, diarrhea, and decreased oral intake, and one day of worsening abdominal pain described as 10/10 and would not take po's in the ED. The patient did not have significant clinical dehydration-- mucus membranes were moist,  cap refill was normal,  HR was normal, BUN/Cr were normal, and was not acidotic. To whatever extent the patient was "dry" due to decreased oral intake, vomiting, and diarrhea, this was corrected by the IV fluid received in the ED. Lipase and amylase were normal, so the patient did not have pancreatitis and did not have any serious abdominal process identified on ultrasound and CT imaging. The corpus luteal cyst was a normal finding, and patient did not have ovarian torsion. When examined by GYN  it was clear the patient did not have a serious medical condition. Despite the description of the pain as 9-10/10, the heart rate remained normal, which is an unusual finding for someone experiencing pain rated this severe. The providers documented some psychosocial issues overlaying the pain experience. After this determination, and after being seen by social work and child life, it would have been reasonable and safe to treat the patient at a lower level of care, with close follow up. In the ED and the hospital, there was a disconnect between the laboratory, radiographic, and vital sign findings, and the reported subjective experience of the abdominal pain. Addressing this disconnect can be challenging, so allowing one inpatient hospital day is reasonable for this patient.