Appeal type: Medical necessity
Decision: Upheld

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

This is a female patient with a significant past medical history of gastritis, eye sarcoidosis, and nephrolithiasis. She presented to the emergency department with complaints of abdominal pain. She started experiencing abdominal pain while lying in bed, which she described as soreness initially but worsened to unbearable pain rated at 10/10 severity. The pain was associated with nausea and approximately 10 episodes of vomiting bilious contents. The patient denied vomiting blood or changes in bowel movements and stated that the pain was similar to her usual gastritis pain, with multiple previous episodes of similar symptoms.
Abdominal tenderness was aggravated by palpation in the epigastric region. The patient displayed intermittent hysterical outbursts due to pain followed by moments of calm.
A computed tomography (CT) scan of the abdomen and pelvis revealed thickened bowel in the distribution of the cecum, ascending colon, transverse colon, descending colon, sigmoid colon, and rectum.
The patient was admitted to the hospital with a diagnosis of intractable abdominal pain due to alcohol-induced gastritis. The admitting physician also suggested ruling out inflammatory bowel disease. Treatment included intravenous fluids, antiemetics, proton pump inhibitors, and intravenous pain medications. During the hospital stay, the patient's diet was advanced, and she was seen by the gastroenterology (GI) service, which considered alcohol gastritis as the cause of her nausea and vomiting episodes. No endoscopic studies were performed during this admission.
The patient was discharged from the hospital with instructions to follow up with GI and consider endoscopic studies. At issue is the medical necessity of an inpatient stay.

The hospital stay was not medically necessary for this patient at the acute inpatient level of care. There was no compelling clinical reason why the patient could not have safely and appropriately received evaluation and treatment at a lower level of care rather than admission to an inpatient level of care.
Based on the patient's symptoms, results of the laboratory studies, and diagnostic tests, it appears that the patient had acute gastroenteritis. Based on the nationally accepted standards of care, admission at the acute inpatient level of care in cases of gastroenteritis is usually justified when patients present with a severe infection that manifests as bloody diarrhea, or in cases when patients are immunosuppressed. Another indication for acute inpatient level of care is severe abdominal pain or the presence of peritoneal signs on exam. Admission at the acute inpatient level of care is also indicated for patients with toxic megacolon, hemodynamic instability, severe or persistent dehydration, or severe electrolyte and metabolic abnormalities that persist despite observation care. Other indications for acute inpatient level of care include hemolytic uremic syndrome or inability to maintain oral hydration after the emergency department and observation care treatment.
Based on the medical records, the patient's clinical symptoms started to subside soon after admission. The overall recovery was relatively quick. She remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care.