Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain And Vomiting Blood
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male with a past medical history of hypertension, pre-diabetes, coronary artery disease status post CABG (coronary artery bypass graft), cerebrovascular accident status post PEG (percutaneous endoscopic gastrostomy) tube (one year ago - now removed), used to drink alcohol but stopped last year, and active cigarette smoker. He presented to the Emergency Department (ED) complaining of chest pain, abdominal pain localized in his left upper quadrant, and epigastric regions, sore throat, nausea and vomiting blood since the night before. He stated that he had the chest pain first followed by "a lot" of episodes of red blood in vomit. On the morning of his ED (emergency department) visit, he had three episodes of bloody vomit associated with painful swallowing. He endorsed having run out of his medications for two weeks and only taking aspirin. 

In the ED (emergency department), the patient e was hemodynamically stable and afebrile. His vital signs were temperature 97.1, heart rate 94, respiration rate 20, blood pressure 135/95, and oxygen saturation 94%. On exam, his epigastrium was tender to palpation with no rebound tenderness. His notable lab results were Hb/HCT (hemoglobin/hematocrit) 16.1/49.2, white blood cell count (WBC) 13.0, lipase 60, glucose 200, and creatinine kinase 350. His electrocardiogram (ECG) showed sinus rhythm at 85 beats per minute. His chest x-ray showed no acute findings. 

In the ED (emergency department), the patient was treated with intravenous (IV) ondansetron, IV (intravenous) loading dose of pantoprazole two times, continuous infusion of pantoprazole, and IV (intravenous) ceftriaxone two times.  He was evaluated by the gastroenterologist, who recommended an endoscopy (EGD) the next day after medical clearance.
 
The patient was admitted to the general medical floor. The plan of care included nothing by mouth (NPO), cardiology clearance after second troponin and transthoracic echocardiogram (TTE), continue pantoprazole drip, trend hemoglobin and hematocrit, and insulin coverage with Lispro. His repeat Hb/HCT (hemoglobin/hematocrit) remained stable at 15.1/48.3 

The patient was cleared by Cardiology. The EGD (esophagogastroduodenoscopy) was performed, which showed congested duodenum, nonbleeding gastric ulcer, gastritis, 2 cm (centimeter) hiatal hernia, LA (Los Angeles) Grade D esophagitis throughout his whole esophagus with a single small diverticulum, and small inlet patch in the upper esophagus. Biopsies were taken. The physician noted that the abdominal pain, nausea, vomiting, and hematemesis were most likely from gastritis versus a gastric ulcer.

The patient was tolerating a regular diet. His vital signs and lab results were stable. There was no change in his Hb/HCT (hemoglobin/hematocrit), and he had no recurrence of GI (gastrointestinal) bleed. He was discharged with instruction for proton pump inhibitors two times per day for six to eight weeks, and then daily sucralfate suspension 1 gram four times daily for two to three weeks, and GI (gastroenterology) follow-up in the clinic in three to four weeks.

No, the Inpatient Admission was not medically necessary. 

The patient was admitted with abdominal pain, nausea, vomiting and hematemesis. In the ED (emergency department), he was hemodynamically stable and afebrile. His Hb/HCT (hemoglobin/hematocrit) were normal. In the ED (emergency department), he was started on IV (intravenous) fluids and IV (intravenous) Protonix drip, and also given two doses of IV (intravenous) antibiotics. The GI (gastroenterologist) was consulted and recommended EGD (esophagogastroduodenoscopy) after the medical clearance. The patient was made NPO (nothing by mouth) and continued on IV (intravenous) Protonix drip. Since he has a history of CAD (coronary artery disease) status post CABG (coronary artery bypass graft), he was evaluated by Cardiology and was cleared for EGD (esophagogastroduodenoscopy) after the cardiac valuation.

The patient underwent EGD (esophagogastroduodenoscopy), which revealed severe esophagitis and non-bleeding gastric ulcer. The following day he was able to tolerate diet and he had no recurrence of GI (gastrointestinal) bleed. His Hb/HCT (hemoglobin/hematocrit) remained stable. He was discharged home on proton pump inhibitors and Carafate suspension, and follow up on an outpatient basis. 

Since the patient remained hemodynamically stable during his hospital stay and had no recurrence of hematemesis, and he did not require any blood transfusion or surgical intervention, he could have safely managed under the lower level of care. The Inpatient Admission was therefore not medically necessary.