Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay
The determination is upheld.


The patient has a past medical history significant for type 2 diabetes mellitus, hypertension, gastritis, asthma, and medical noncompliance and presented to the hospital with a three-day history of shortness of breath, nausea, vomiting, and abdominal pain. Her symptoms started several days before the presentation after heavy consumption of alcohol. When the patient was seen by the admitting physician, she complained of abdominal pain that was diffuse, non-radiating, without modifying factors. The shortness of breath was not associated with orthopnea or paroxysmal nocturnal dyspnea. The patient reported daily marijuana use.
The review of systems was negative for a fever, chills, cough, chest pain, palpitations, dizziness, loss of consciousness, or headache.
When the patient was seen by the admitting physician, she was afebrile. The heart rate was 118 beats per minute (bpm), blood pressure 150/88, respiratory rate 18 breaths/minute, and oxygen saturation 98% on room air.
The abdomen was soft, nontender to palpation, with normal bowel sounds, without guarding or rebound. The rest of the physical exam was unremarkable.

The patient was admitted to the hospital with right lower quadrant abdominal pain that was associated with nausea and vomiting. The differential diagnosis included appendicitis, ectopic pregnancy, acute pancreatitis, hyperemesis due to marijuana. The admitting physician stated that the computed tomography (CT) scan of the abdomen and pelvis was negative for acute abdominal pathology. There was no evidence of small bowel obstruction.
In the hospital, the patient received treatment with intravenous fluids, pain medications. Initially, she was kept nothing by mouth (NPO).
Another clinical diagnosis at the time of admission was metabolic alkalosis, which was attributed to vomiting. The treatment for this condition was the administration of intravenous fluids. In addition, the patient received potassium supplements for the treatment of hypokalemia. Diabetes mellitus was treated based on basal/bolus insulin coverage.
In the hospital, the patient was seen by a gastroenterology (GI) specialist who suggested that the patient's symptoms were likely related to alcohol gastritis. The patient was recommended treatment with Pepcid. The GI specialist did not recommend any intervention.
In the hospital, the patient was evaluated by the infectious disease service because of leukocytosis. According to the infectious disease specialist, the leukocytosis was reactive, and there was no need for the administration of antibiotics.
Since the patient's condition continued to improve during the hospital stay, she was discharged home. At issue is the medical necessity of an inpatient stay.

The requested health service/treatment of inpatient stay was not medically necessary at the acute inpatient level of care. The hospital stay was not medically necessary for this patient at the acute inpatient level of care.
There was no evidence that the patient had a true hypertensive emergency. There was no target organ damage. The mild elevation of creatinine was likely related to dehydration due to diminished oral intake, nausea, and vomiting. The mild elevation of creatinine resolved quickly.
Even though the patient had abdominal pain, there was no evidence that she had a problem requiring admission at the acute inpatient level of care. The abdominal pain was most likely related to alcoholic gastritis. It significantly improved after treatment with Pepcid. Even though she complained of shortness of breath, objectively, she was not in acute respiratory distress. This patient had a normal respiratory rate and oxygen saturation.
Overall, during the hospital stay, the patient remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care.
At the time of the initial evaluation, the patient had abdominal pain that required further evaluation. She also had laboratory abnormalities for which she needed administration of intravenous fluids and continuous monitoring. Even though the patient had clinical symptoms that required immediate attention, neither the severity of the patient's condition nor the complexity of services provided rose to the acute inpatient level of care.
Care could have been provided at a lower level.