Appeal type: Medical necessity
Decision: Upheld

Digestive System/Gastrointestinal - Abdominal/Stomach Pain
Inpatient Hospital

The patient is a male with medical history of hypertension, deep vein thrombosis status post inferior vena cava filter on chronic anticoagulation with Xarelto, dementia, seizure disorder, and hypertension. He presented to the emergency department with severe (10/10 in intensity) sudden-onset (during sleep) right lower flank pain exacerbated by movement and palpation. He noted recent passage of black bowel movements. He had ongoing vomiting in the emergency department.

Vital signs were notable for hypertension with blood pressure of 172/90 millimeters of mercury (mmHg). Physical examination was notable for tenderness to palpation in the right lower quadrant of the abdomen. Chest x-ray showed no acute findings. Computed tomography scan of the head showed evidence of right craniotomy with underlying encephalomalacia in the right temporal and bifrontal lobes, with prominent supratentorial and infratentorial ventricular system and subarachnoid spaces reflecting cerebral and cerebellar atrophy. Computed tomography scan of the abdomen and pelvis showed ground-glass opacities in the lung bases and several subpleural right lower lobe nodular densities. Computed tomography scan of the lumbar spine showed degenerative changes at L5-S1 with bilateral foraminal narrowing and central spinal stenosis. Renal ultrasound showed no acute findings. He was treated with multiple doses of intravenous morphine and methocarbamol. Physical Medicine/Rehabilitation consultation recommended local ice or heat, physical therapy with home services, and consider acetaminophen. Pain Management consultation  recommended continuation of medications and consider Tylenol III. He had lumbosacral back pain, but no melena, nausea, vomiting, or abdominal pain. Labs showed a low potassium of 3.0 mEq/L. X-ray of the right hip showed no evidence for fracture dislocation, and some degenerative arthritic changes. X-ray of the right femur showed some degenerative changes in the right hip joint, and a previous fracture with deformity and callus at the midportion of the right femur. Neurosurgery consultation recommended conservative treatment with nothing to be treated surgically, and clinic follow-up after physical and occupational therapy, and pain management. On the day of discharge, he had difficulty ambulating. Labs showed a low potassium of 3.1 mEq/L. He was discharged with a diagnosis of back pain secondary to lumbar radiculopathy due to central spinal stenosis, and no change in pain management; Gastroenterology follow-up was recommended if melena was noted in the future. At issue is the medical necessity for the inpatient level of care.

The health plan's determination is upheld.

No, the acute inpatient level of care is not supported in this case.  In this case, the patient presented with symptomatic visible gastrointestinal bleeding (melena). However, there was no sustained hypotension or tachycardia, and no anemia; hemoglobin remained stable. The patient had close monitoring, which was warranted as bleeding can be severe and sudden in onset [1-4]. No endoscopic investigation was deemed necessary, and no further visible gastrointestinal bleeding occurred. Back pain was evaluated extensively, with multiple specialist consultations recommending conservative therapy and pain management; no intervention requiring the inpatient level of care was recommended, and a plan for outpatient follow-up was made [5,6]. All of the measures that were undertaken, including monitoring and specialist consultations, could have been performed without acute inpatient level of care [2-6].