Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain

Treatment: inpatient hospital admission

The insurer denied coverage for inpatient hospital admission

The denial is upheld.

The patient has a past medical history notable for intermittent asthma that presented by ambulance to the Emergency Department for assessment and management of 1 day of 5/10 right lower/right upper abdominal pain, non-bloody diarrhea and decreased appetite for one week. There was no associated nausea, vomiting, fever, bleeding, weight loss or dysuria. The patient's vitals on arrival were notable for heart rate (HR) 114 temperature (T) 98.2, respiratory rate (RR) 20, blood pressure (BP) 114/75 and room air oxygen saturation of 98% (percent). Admitting weight was 27.4 kilograms and height was 124 centimeters. Physical exam showed an awake and alert male in no apparent distress. He had moist mucus membranes with normal capillary refill and normal skin turgor. Lungs were clear with normal effort. Cardiac exam was unremarkable. Abdomen exam was soft with tenderness to palpation in the right lower quadrant with voluntary guarding. There was no associated organomegaly, distension, rebound, or masses. There was no rectal exam reported. Admitting laboratories were notable for sodium 136, potassium 4.4, bicarbonate 20, blood urea nitrogen (BUN) 17, creatinine 0.3, white blood cell 13.4 (neutrophils 68%, no bands), hemoglobin 12.5, platelet 328, and C-Reactive Protein (CRP) 0.85. Urinalysis was notable for specific gravity 1.017/pH (potential of hydrogen) 6 and dip negative. Nasal viral washings were negative. Imaging included an abdominal sonogram showing a non-dilated compressible appendix.  An abdominal CT (computed tomography) scan showed a normal appendix, retained stool, a thickened distal ileum and non-specific scatter mesenteric lymph nodes. 
 
This child appears to have abdominal pain secondary to viral-induced mesenteric adenitis. He did not appear dehydrated and had no red flags to suggest a serious condition.  In accordance with a review of the approach to emergency  evaluation of acute abdominal pain in children from UptoDate the reasons to admit such an individual would include signs of significant dehydration poorly responsive to intravenous hydration in the Emergency Department, hemodynamic instability, significant electrolyte imbalance, demonstrated oral hydration intolerance to oral challenge, poorly controlled pain with an oral pain medication regimen, concerning physical exam findings for a surgical process or findings consistent with significant blood loss or bowel obstruction. He did not meet any of these criteria to merit the inpatient setting. The evaluation performed prior to admission excluded serious possible causes of his symptoms. His pain did respond to treatment in the Emergency Department with multiple notes documenting pain improvement.  Once admitted his pain was controlled on oral medications.
 
"Degree of dehydration - Fluid repletion guidelines for children with gastroenteritis by the American Academy of Pediatrics, Centers for Disease Control, and the World Health Organization are based upon the degree of volume depletion. As a result, it is important to be as accurate as possible when assessing the degree of dehydration. Severe hypovolemia requires rapid isotonic fluid resuscitation, although oral rehydration may be sufficient for mild to moderate hypovolemia.

The documentation of this child's appearance and vitals would indicate no dehydration necessitating admission to the hospital for monitoring of strict intake and output. It seems he tolerated the oral contrast for his CT scan prior to admission and received multiple oral medications that he tolerated as well. Vomiting was never part of his presenting symptoms and may have been related to the pain medications given while in the Emergency Department. After an evaluation excluded dangerous conditions, he could have been safely discharge on oral pain medications with outpatient follow-up. He received no acute care after admission to merit reimbursement at that level. In regard to the acute inpatient admission the determination by the carrier that the admission was not medically necessary was correctly applied, objective, clinical valid, compatible with established principles of health care and flexible enough to permit justified variation. This decision was rendered based on review of the hospital record and the attached reviews from UptoDate summarizing the approach to acute abdominal pain in children and dehydration in children.

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for the inpatient hospital admission is not substantiated. The insurer's denial is upheld.