Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Abdominal Pain.
Treatment:  Inpatient Hospital Stay.

The insurer denied the Inpatient Hospital Stay.  The determination is upheld.

The patient presented to the emergency department (ED) having been sent by his primary doctor with complaints of chronic abdominal pain of 5-weeks duration, nausea, vomiting and diarrhea.  Comorbid health conditions include a history of atrial fibrillation, alcohol abuse, anxiety, asthma, hiatal hernia, high cholesterol, hypertension, morbid obesity, and sleep apnea.  At the time of presentation, his vital signs were normal.  Examination identified a soft, non-distended and slightly tender lower abdomen.  His hemoglobin was 13.5, white blood cell count (WBC) count was normal at 7.5 thousand (K).  Electrolytes and renal function were normal.  A computed tomography (CT) scan showed no bowel obstruction, anatomic changes of prior sigmoid colon resection, and no free air or ascites.  There was a small right periumbilical hernia containing fluid and a short segment of small bowel similar to a prior exam.  There was no evidence for appendicitis.  The patient was maintained as an acute inpatient admission.  At issue is the medical necessity of an inpatient stay. 

Inpatient stay was not medically necessary for this patient, who was clinically stable at the time of presentation.  This patient presented with complaints of 5-weeks of abdominal pain and hematemesis and bloody diarrhea.  He was appropriately treated for these complaints with labs and CT imaging that identified a nonobstructive ventral hernia.  The endoscopy procedure that was performed could have reasonably and appropriately been performed at a lower level of care and did not require inpatient admission for this patient with a normal hemoglobin and no active gastrointestinal (GI) bleeding with normal vital signs.

Additionally, while this patient did have a ventral hernia, there was no clinical evidence for obstruction, and this hernia did not require emergency intervention.  Surgical repair of the ventral hernia could also have been performed at a lower level of care and did not require inpatient admission.  The records do not indicate that there was a clinical need for or indication for inpatient admission.  This patient was afebrile, was clinically stable, was tolerating diet prior to endoscopy, and was without signs for infection or other acute pathology.  Inpatient hospital stay was not medically necessary per generally accepted standards of medical care.

On the day after admission, the patient continued to complain of abdominal pain.  There was no nausea/vomiting, bloody bowel movements or fever.  He was described as clinically stable.  An endoscopy was performed showing mild esophagitis and gastritis.  A colonoscopy identified a polyp of the colon.  His diet was resumed.  The abdominal pain had improved and he was tolerating a diet.  The plan was for an umbilical hernia repair during this admission.  His vital signs were normal, and he was tolerating a diet.  

He underwent a laparoscopic incisional hernia repair and lysis of adhesions.  He complained of abdominal pain, palpitations and chest tightness.  Vital signs showed tachycardia.  He was evaluated with a venous duplex study, chest computed tomography (CT) scan and was treated with pain medications.  There was no imaging abnormality to suggest a pulmonary embolism.  He complained of difficulty breathing and abdominal pain.  The diet was stopped, and he was made nothing by mouth (NPO).  The pain complaints improved, and his diet was resumed.  The progress notes document progressive improvement.  A note states that the patient has been ready for discharge for the past 2-days but was refusing discharge because he had no one at home to help him.