Appeal type: Medical necessity
Decision: Upheld

 Diagnosis: Epigastric Pain

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

As per the triage note, the patient came to the emergency department (ED) with complaints of pain and stating that they think they have an ulcer. The patient was afebrile with stable vital signs. The ED provider note indicated the history of 5/10 constant burring substernal chest pain. The pain had been worse since the prior day. The patient is status-post gastric sleeve and Roux-en-Y Gastric Bypass (RYGB) and has a history of 2 marginal ulcers. The patient denied vomiting, nausea, bright red blood per rectum, and dizziness. On exam the patient's abdomen was non-distended, there was epigastric tenderness, but no rebound or guarding. Labs and x-rays were reviewed. The patient was admitted to surgery.  

As per the history and physical, this is the case of a patient with history of depression, gastric sleeve x 2 and gastric bypass who presented with epigastric pain. The pain started with a burning sensation and chest pain.  The patient normally had this issue since after the bypass, but it previously resolved with Omeprazole.  However, this time it persisted.  The patient had an esophagogastroduodenoscopy (EGD) which showed 2 marginal ulcers. On exam the patient was hemodynamically stable with no significant labs. A computed tomography (CT) showed inflammatory change at the level of the gastro enteric anastomosis and fat stranding in this region also contiguous with the nearby/adjacent bypass stomach where there is mural thickening.  The patient was afebrile with stable vital signs. Labs revealed normal amylase, white blood cell count (WBC) 9.2, hematocrit (Hct) 32.2, and normal liver function tests (LFT's). Ultrasound of the abdomen showed non-specific right renal fullness. CT of the abdomen showed status-post RYGB with focal inflammatory changes at the level of gastro enteric anastomosis. There was mural thickening of the bypassed stomach consistent with gastritis. The assessment was abdominal pain most likely due to marginal ulceration. The plan was nothing by mouth (NPO), intravenous (IV) fluid, proton-pump inhibitors (PPI) twice daily (bid), monitor abdominal exam, possible EGD, and admit to surgery.

According to the progress notes the following day, it indicated the patient was awaiting an EGD. An EGD was done that day which showed a small marginal ulcer. The patient was discharged to home that day in stable condition.

In this case the patient should have been managed as an outpatient without acute inpatient hospitalization as they should have had the EGD done without an inpatient admission. The patient was hemodynamically stable throughout and did not need an acute admission but rather observation as they had no other findings except the history of burning sensation and past history of 2 marginal ulcers. Endoscopy is an outpatient procedure, and, in this case, observation was all that was needed. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for full hospital admission is not substantiated.