Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Mass of colon, Vomiting, and Intractable abdominal pain.
Treatment: Inpatient hospital admission.
The insurer denied coverage for the inpatient hospital admission.
The denial is overturned.

This is a female patient with a past medical history of diverticulitis, chronic back pain (on Suboxone), partial colectomy, and cholecystectomy.  The patient presented to the Emergency Department (ED) with subjective complaints of periumbilical and left-sided abdominal pain with associated nausea and vomiting for 5 days.  The patient reported that she was seen in the ED during the week and was given intravenous (IV) fluids and blood work, and was sent home on Zofran.  The patient stated that her pain had not improved and she still had persistent nausea and diarrhea.  The patient had not been able to keep food down and reported multiple episodes of foul-smelling diarrhea daily.  The patient had no other complaints and denied fever, chills, chest pain, shortness of breath, headache, dizziness, neck pain, back pain, lower extremity edema, numbness, or tingling, dysuria, or hematuria.  The patient's blood pressure was 131/61 and her heart rate was 61.  The physical examination revealed positive periumbilical abdominal tenderness to palpation.  There was no costovertebral angle (CVA) tenderness to palpation.  The patient's abdomen was non-distended.  There was no rebound or guarding.  The patient's bowel sounds were normal in all 4 quadrants.  The patient's computed tomography (CT) scan of the abdomen and pelvis showed short segment mass-like bowel wall thickening at the hepatic flexure with mild surrounding fat stranding.  The provider recommended a colonoscopy to exclude underlying mass lesion.  The patient was treated with intravenous fluids and morphine sulfate.  The patient's pain had improved, but it was still present.  The evaluation and management determined that the patient had a medical necessity beyond the capabilities of the ED for possible vomiting, intractable abdominal pain, and an abdominal mass.  The patient was admitted with diagnoses including mass of colon, vomiting, and intractable abdominal pain.  The patient was treated with Zofran orally and was started on oxycodone and hydromorphone orally.  The patient was given antibiotics for 14 days.  The patient was also started on oral Suboxone.  The patient underwent a colonoscopy with findings of no inflammatory or neoplastic lesion in the colon.  

Based on the review of the medical record and literature, inpatient hospital admission was medically necessary for this patient. The patient presented with acute abdominal pain to the Emergency Department (ED). Except for the abdominal tenderness, there was no other lab or vital signs finding that indicated acuity. However, the patient had already been discharged from the ED previously and came back with similar symptoms. Outpatient management would not have been a good option. The patient's computed tomography (CT) scan showed thickening of the colon which could have explained her abdominal pain. The patient's prior medical history in itself does not warrant any greater need for admission. However, given this patient's persistent severe abdominal pain, abnormal CT scan, and recurrent visits to the ED, inpatient admission was medically necessary at this point. The patient had failed outpatient management.

The inpatient admission is considered medically necessary for this patient.

The health plan did not act reasonably with sound medical judgment and in the best interest of the patient.

The medical necessity for the inpatient hospital admission is substantiated.  The insurer's denial should be overturned.