Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Constipation
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female with a history of lifelong constipation. She presented to the ED (emergency department) with complaints of constipation, abdominal distention and pain. Her recent medical history is significant for a sigmoidectomy in conjunction with a supracervical hysterectomy and bilateral salpingectomy performed. The patient notes that she had been on Trulance for her bowel problems, but that it was not resumed following her surgery. A referenced recent CTAP (computerized tomography of the abdomen and pelvis) noted a large fecal burden, and a sigmoidoscopy one week prior to her presentation documented a patent anastamosis with stool in the colon. On the day of admission, she underwent an out-patient gastrograffin enema, which was concerning for a possible stricture and was advised by her physician to proceed to the Emergency Department.

On exam the patient's abdomen were noted to be distended, soft and mildly tender. Vital Signs were stable and laboratory studies were unremarkable, except for the presence of anemia. The patient was admitted to acute inpatient care.

Following admission, the patient received IV (intravenous) fluids, anti-emetics and purgatives. On admission day two she underwent a colonoscopy. The procedure note documents minimal residual stool within the colon. A mild stenosis is noted in the proximal rectum (presumed at the anastamotic site). It is traversed and dilated. She was discharged home from the hospital later that same day, to be followed in the office. She was discharged home on Trulance.

The health plan has denied the in-patient admission as not medically necessary. The provider has appealed this determination noting abnormal findings, risk factors and the medically necessary treatment rendered during her stay as supporting factors.

No, the Inpatient admission was not medically necessary.
The patient suffered from "lifelong" constipation with a recent exacerbation following surgery compounded by failure to resume pre-procedure medications in the post-operative period. Multiple studies - performed on an ambulatory basis - prior to her presentation in the ED (emergency department) documented no evidence of an acute process or post-operative complications and were consistent with her history of constipation. Evaluation in the ED (emergency department) evidenced no laboratory abnormalities or findings on physical exam that warranted admission. Her constipation resolved with the administration of oral agents as evidenced by her colonoscopy report the following day which notes minimal residual fecal material.

The patient's presenting complaints and the care rendered to resolve them did not rise to the level necessitating acute inpatient status. The denial should be upheld.

The health plan correctly identified that the patient did not require admission to the hospital and that her care should have been rendered at a lower level of care. This determination evidences sound medical judgement on the part of the plan. The management of her condition on an ambulatory basis is in the best interest of the patient as well.