Appeal type: Medical necessity
Decision: Overturned

The patient is a female with history of epilepsy, colon cancer with resection status post end to end ileostomy, presented to the emergency department, with colicky intermittent abdominal pain, located in the periumbilical area, with radiation to the back. There is no associated dyspnea or chest pain. The patient has a history of small bowel obstructions, and the pain felt similar. The patient did experience a bowel movement earlier on the day of presentation but is currently experiencing nausea with no vomiting. There were no associated fevers chills or fatigue. On exam, the patient is described as a nontoxic-appearing female. The abdomen is soft but distended with no focal tenderness to palpation, large midline scar, and no palpable hernias. The rest of the exam is unremarkable. Given the prior history of small bowel obstructions, this was on the top of the differential, however, the presence of hypertension and pain radiating to the back, dissection needed to be ruled out. Therefore, the patient was admitted to the clinical decision unit, an angiogram of the aorta with oral (p.o.) contrast was ordered. The patient was provided with intravenous (IV) fluids, bowel rest. Laboratory studies revealed a normal white blood cell count, lactic acid of 1.2, normal creatinine and normal electrolytes. Hemoglobin was 13.9. Liver function tests were normal as well. Urinalysis showed moderate leukocyte esterase and 5-10 white blood cells. Cardiac troponin was normal. The computed tomography (CT) angiogram of the abdomen was done, which showed no aortic aneurysm or dissection. There was a long segment wall thickening of the ileal bowel loops in the anterior mid and lower abdomen, with some loops of dilated measuring up to 3.2 centimeter (cm). The appearance could be related to mild ileus, enteritis or ischemic etiology. The patient was started on oral Cipro and Flagyl.
The patient was provided applesauce, as part of the advancement of diet, while in the clinical decision unit, and unfortunately experienced ongoing abdominal pain. At this point, she was admitted to the hospital for further evaluation and management. Gastroenterology was consulted, to assess, as well as surgery. The pain was controlled with acetaminophen. Antibiotics were changed to IV, and the patient was made strict nothing by mouth (n.p.o.). The vital signs included a temperature of 97.2, a heart rate of 57, blood pressure of 164/51, with respirations of 20. Repeat abdominal exam showed a soft nontender nondistended abdomen, with audible bowel sounds, healed the surgical scar, and palpable mesh just under the umbilicus. The gastroenterologist felt that the patient's CT scan is inconsistent with small bowel obstruction. Stool cultures and Clostridium (C.) difficile were sent, due to the infectious appearance of the small bowel on the CT.
The patient was also evaluated by general surgery, who reviewed the patient's imaging and reassessed the patient's abdomen, describing it is soft nontender and nondistended. They agreed with the diagnosis of gastroenteritis and recommended keeping the patient on a clear liquid diet until the pain resolved.
The following day, the patient was able to tolerate clear liquid diets, she was feeling more comfortable, however, the abdomen remained firm and distended with increased high-pitched bowel sounds. The diet was cautiously advanced.
The following day the patient has significant improvement of the abdominal pain, passing flatus, has normal white blood cell count, with no shift, and has remained afebrile. No surgical intervention was necessary, endoscopy was deemed unnecessary at this point. Unfortunately, the patient was intolerant of ciprofloxacin, developed some watery diarrhea, and was switched over to ceftriaxone. C. difficile stool tests were negative. Given the improvement in the symptoms, and stabilization of vital signs, the patient was deemed stable for discharge. Colonoscopy was recommended in 6 weeks as an outpatient.
The question at hand is the medical necessity of the inpatient stay.

The health plan's determination is overturned.

The patient failed observation level of care, due to persistent abdominal pain, with the advancement of diet. As a result, the specialist involved in her care recommended strict n.p.o. status, and therefore the patient had a limited ability to maintain oral hydration and required IV fluid support. This persisted beyond the observation care treatment. The patient also needed antibiotic therapy, which was provided in the IV form, in order to rest the bowels. As a result, clinically, this patient satisfies indications for admission to inpatient care, ongoing monitoring for peritoneal signs. The progress notes state that the abdomen is tender and firm, and required ongoing serial exams, to ensure peritonitis is not developing. The patient required failed observation level of care, and required ongoing treatment in the hospital, which can only be provided under the inpatient level of care.