Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Small bowel obstruction
Treatment: Full hospital admission
The insurer denied the full hospital admission
The denial is upheld.

The patient is a female who had recently been admitted to the hospital for the condition of small bowel obstruction. She had been discharged. She presented to the emergency department (ED) with ongoing abdominal symptoms. Her ED evaluation included labs and a computed tomography (CT) scan that suggested a small bowel obstruction with a transition point in the mid small bowel. At the time of presentation, the patient was without fever and vital signs were normal. The white blood cell (WBC) count was normal. The complete metabolic panel identified normal liver enzymes, normal renal function and normal electrolytes.

The patient was initially treated with intravenous (IV) fluid and nothing by mouth (NPO) status. Surgical consultation was requested. CT enterography identified that the previously seen proximal small bowel distention and right upper quadrant transition point was no longer identified. The patient reported no abdominal pain or vomiting. Vital signs were normal. Abdominal exam was normal. The diet was advanced. The patient remained clinically stable with normal vital signs and no reported abdominal pain. She was discharged from the inpatient setting.

The subject under review is the medical necessity for the full hospital admission.

The health plan's determination is upheld. There is no compelling reason why this patient could not have safely and appropriately been treated with a lower level of care.

An inpatient level of care was not medically necessary in this case. This patient is without reported comorbid illness. She presented to the hospital ED with abdominal complaints following a prior hospital evaluation and discharge. Evaluation at the ED suggested a bowel obstruction. The patient was hemodynamically stable at the time of presentation. Further evaluation with CT enterography showed resolution of the CT findings that suggested bowel obstruction and the patient was without symptoms of pain or vomiting. There is no documentation of hemodynamic, pulmonary, neurological, or metabolic reason for an acute inpatient level of care at the time of presentation. Surgery consultation was requested. While the patient was initially NPO, she was able to be started on a diet within one-day.

There is no documentation of need to care for comorbidities that required inpatient admission or any other condition requiring inpatient admission. Acute inpatient care was not medically necessary for this patient as the care and treatment provided could have been rendered with a lower level of care. This lower level of care would have provided for surgical consultation, provision of IV fluid, imaging, lab assessment and overnight care. A lower level of care would have been consistent with the Milliman Care Guidelines (MCG) criteria in this case.

Inpatient stay related to bowel obstruction may be needed for complete bowel obstruction or partial obstruction with significant signs or symptoms such as inability to maintain oral hydration, vomiting, significant pain, electrolyte abnormalities, or care for active comorbidities. In this case none of these conditions existed and the patient had resolution of her abdominal complaints within one day.