Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient hospital admission.  The denial has been upheld. 

The inpatient designation was not medically necessary.

This patient is a female who presented to the hospital emergency department with complaint of abdominal pain of 5-days duration.  Comorbid health conditions included a history of roux en Y gastric bypass performed for the diagnosis of morbid obesity.  

The records indicate that the patient was evaluated with computed tomography scan and surgical consultation.  The computed tomography showed anatomic changes of gastric bypass and mild gaseous distention of several small bowel loops.  There was also a distended gallbladder with stones.  Vital signs on the day of admission were normal.  Lab data identified a normal white blood cell (WBC) count and elevated alkaline phosphatase of 121.  The patient was mildly tender over the left inguinal area.  Lab data was normal.  He was monitored overnight.  Vital signs were consistently normal during the period of monitoring.  The patient underwent a combined endoscopic and laparoscopic procedure the next day.  Endoscopy identified a marginal ulcer at the gastrojejunostomy and laparoscopy identified normal and expected roux en Y gastric bypass anatomy without mesenteric volvulus. The operative dictation makes no mention of the gallbladder (despite gallstones having been identified on computed tomography scan).  The patient was able to tolerate a diet and oral analgesia as of the day of discharge.  The patient was discharged from the hospital with prescriptions for Carafate and omeprazole.

The patient was evaluated with examination, labs and imaging.  Computed tomography scan showed gallstones and anatomic changes of gastric bypass.  The patient underwent a combined endoscopic and laparoscopic procedure the day after admission.  Endoscopy identified a marginal ulcer at the gastrojejunostomy and laparoscopy identified normal and expected roux en Y gastric bypass anatomy without mesenteric volvulus. The operative dictation makes no mention of the gallbladder (despite gallstones having been identified on computed tomography scan).  

The medical records indicate that this patient presented to the emergency department with abdominal pain secondary to a marginal ulcer.  She was clinically stable at the time of presentation and remained so during the period of monitoring.   Endoscopy alone would have provided the diagnosis and established the treatment plan for this patient.  The patient had consistently normal vital signs, was able to tolerate a diet and oral pain medications and was stable for discharge from the hospital on the first post-surgical day.  

The records support that the care and treatment provided to this patient did not require an inpatient level of care.  A lower level of care would have permitted surgical evaluation, monitoring, and follow up. 

An inpatient level of care was not necessary to treat this patient's condition, was not in accordance with generally accepted standards of medical practice, was not clinically appropriate in terms of extent or duration, and there was an equally effective alternative lower level of care.  This patient presented with a marginal ulcer post gastric bypass.  She did require assessment with upper endoscopy as was performed.  She was clinically stable with normal vital signs prior to and following this procedure and was able to be treated with prescribed medications (omeprazole and Carafate).  The patient was able to tolerate a diet on the day of discharge.  The care and treatment provided could have appropriately been rendered with a lower level of care.  

There is no clinical documentation to support the need for inpatient care admission.  The patient was clinically stable, did not require complex nursing care, and did not require titration of intravenous medications or other intervention that would require inpatient care admission.