Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Abdominal Pain.
Treatment:  Inpatient Hospital Admission.

The insurer denied Inpatient Hospital Admission.  The denial is upheld.

This patient is an adult female (body mass index [BMI] 25 kilograms per meter squared [kg/m2]), who presented to the emergency department with complaints of abdominal pain of one to two days duration. She had had bariatric surgery two years ago (conversion of sleeve gastrectomy to roux en Y gastric bypass) as treatment of morbid obesity. Vital signs were normal at the time of emergency department presentation (heart rate 88 beats per minute). The emergency department provider notes describe a tender abdomen. The white blood cell (WBC) count was normal at 6.6 thousand. Computed tomography scan showed findings of prior roux en Y gastric bypass and swirling of the mesentery consistent with mesenteric volvulus related to an internal hernia. Comorbid health conditions included hypertension, hyperlipidemia, diabetes, and sleep apnea.

The records indicate that the patient underwent laparoscopic reduction and repair of the internal hernia on day #2. The anesthetic record documents that the operation required approximately two hours to complete. The operative dictation describes findings of chylous ascites and closure of a small Petersen space defect. Upper endoscopy was also performed with findings of a normal gastrojejunal anastomosis. The patient remained hemodynamically stable with normal vital signs following surgery. On day #3 the patient had normal vital signs and her pain was well controlled. The diet was advanced. The discharge summary states that the operative and postoperative course was uncomplicated, and the patient was cleared for discharge. A discharge note states that the patient was discharging home with self-care. The submitted documentation references Milliman Care Guidelines (MCG) Abdominal Pain, Undiagnosed 26th edition. The health plan rationale for denial is that the care provided did not require an inpatient setting as there was no hemodynamic, sepsis, severe finding such as bowel perforation, ischemia, or obstruction, or need for open surgery.

Inpatient level of care was not required or medically necessary.

This patient had an internal hernia related to prior roux en Y gastric bypass that was performed two years ago. The patient presented to the hospital due to abdominal pain symptoms. She was hemodynamically stable at the time of presentation. Her evaluation that included abdominal computed tomography scan was completed in the morning and identified the diagnosis of internal hernia and established the indication for operative intervention. The operation to repair the internal hernia was performed complication. The submitted records document clinical stability in the perioperative period and that the patient met criteria for discharge from the hospital on the first post-surgical day following a period of recovery. In this case the patient was clinically stable at the time of presentation. While she did require emergent surgery, the operation was performed without complication. Lab data prior to surgery and following surgery identified mild aberration of electrolytes that did not require an inpatient designation, and the patient was clinically stable for discharge from the hospital on the first post-surgical day. There were no complications of surgery or active comorbidities that required inpatient care. The patient responded promptly and favorably to the therapy provided. In this case there is no documentation to support that criteria existed to warrant an inpatient level of care. The care during this time could have been rendered with a lower level of care.