Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal/Flank Pain
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay
The determination is upheld.

The patient was brought to the emergency department (ED) with right flank pain. Per the ED note, she had been having generalized abdominal discomfort since the Thursday before. The day before, her physician obtained an ultrasound which was negative for gallstones and appendicitis. She reported "difficulty urinating," but no fevers or chills. Her period began five days previously and ended before arrival to the ED. At triage, she was afebrile with normal vital signs. On exam, she was well appearing, nontoxic, and in no apparent distress. She had right costovertebral angle tenderness on a back exam, but otherwise had a normal physical exam. She was initially treated in the ED with normal saline fluid bolus, Zofran orally, and ibuprofen orally. A urinalysis showed small hemoglobin and small leukocyte esterase, negative nitrites, no red blood cells (RBCs), 5-10 white blood cells (WBCs), and few bacteria. Electrolytes, liver panel, lipase, and a complete blood count (CBC) were normal. A renal ultrasound was normal and negative for stones. An abdominal/pelvic ultrasound was negative. A computed tomography (CT) scan was negative for renal or ureteral stones; there was an incidental finding of a small fecalith along the length of the appendix without inflammatory changes, as well as possible gallbladder sludge. Surgery was consulted and they were not concerned for appendicitis. The ED physician noted that the patient continued to have tenderness on exam, so he contacted the pediatric department for admission for serial abdominal exams and pain control.
The admission history and physical (H&P) documents that the patient had a history of chronic, recurrent abdominal pain, and that with this episode, the abdominal pain began the same day as her menstrual period, but ibuprofen and acetaminophen did not provide the usual relief, and Zantac did not work either. The physical documents normal vital signs, a patient who "appears comfortable, NAD," with a soft abdomen but diffuse abdominal tenderness and bilateral flank pain. The differential diagnosis listed a number of possible etiologies that were noted to have been ruled out or made very unlikely by the work up done in the ED, including urinary tract infection (UTI), pyelonephritis, kidney stone, gallstone, ovarian torsion, ectopic pregnancy, dysmenorrhea. She was observed overnight. Tylenol managed her pain adequately, she tolerated by mouth (PO), and was discharged.
At issue is the medical necessity of an inpatient stay.
The inpatient stay was not medically necessary. The patient had a full ED workup for serious medical, obstetrical, and surgical causes of her flank/abdominal pain, including laboratory evaluation, ultrasound of the upper and lower abdomen, pelvis, and kidneys, CT scan of these areas, and surgical consultation. There were no positive findings. She continued to have the flank/abdominal pain that brought her to the ED, but she was afebrile, with normal vital signs, and appeared fine on exam. She was not dehydrated and did not require IV fluids, she was tolerating POs, there was no concern for sepsis, and concerns for surgical and obstetrical etiologies had been ruled out. She did not require opiates to control her pain--ibuprofen and acetaminophen were sufficient. She was admitted for observation. This could have been achieved at a lower level of care or at home with close follow up. Acute inpatient admission was not medically necessary.