Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bilious vomiting and abdominal pain. 
Treatment: Inpatient admission. 

The insurer denied the inpatient admission. 
The denial is upheld. 

The patient is a female. She presented to the Emergency Department with complaints of a one-day history of bilious vomiting and abdominal pain. The patient has had similar episodes in the past. Physical exam reveals an incisional hernia secondary to a sigmoid resection for diverticulitis and a failed attempt at repair. 

In the ED (emergency department), the patient was noted to be hemodynamically stable, with a  BP (blood pressure) 160/81, HR (heart rate) 73, T (temperature) 97.8, and WBC (white blood count) 8.6 without shift. The abdomen was noted to be distended and tender, but without guarding or rebound. A plain film of the abdomen showed non-specific air fluid levels with gas in the colon to the rectum and was interpreted as showing no evidence of intestinal obstruction. 

A subsequent CT (computed tomography) scan revealed a complex recurrent ventral hernia containing multiple loops of small bowel. A partial small bowel obstruction could not be excluded due to the fact that oral contrast was not administered for the study. The scan was compared to a prior exam and felt to be consistent with and unchanged from the previous scan. Final impression of the CT (computed tomography) scan indicates there was nothing to suggest small bowel obstruction. 

The patient was admitted to acute inpatient status on the surgical service. The daily progress note the following day documents her to have stable VS (vital signs) with a soft, non-distended abdomen with a reducible ventral hernia present. A follow-up CT (computed tomography) scan with oral contrast reveals no evidence of obstruction and resolution of the previously seen air-fluid levels. The plan is to advance diet and ambulate as tolerated. 

The daily progress note of day 1 states that the patient is resting comfortably, the pain and nausea are resolved, is having BMs (bowel movements) and is hungry. She is maintained on oral intake with a plan for surgery, at which time she underwent a robotic repair with mesh of an incarcerated recurrent incisional hernia. She was discharged home the following day. 

No, the Inpatient admission was not medically necessary. 

The patient presented to the ED (emergency department) with abdominal distention and discomfort with associated bilious emesis secondary to a chronic incarcerated recurrent ventral hernia with similar episodes in the past. Evaluation in the Emergency Department revealed her to be afebrile and hemodynamically stable with a normal WBC (white blood count). Physical examination documented only generalized abdominal tenderness without acute or localizing signs. Abdominal films, CT (computed tomography) scan without contrast and a subsequent CT (computed tomography) scan with oral contrast all documented no evidence of either complete or partial intestinal obstruction with findings unchanged from a prior study. The patient responded to supportive care and could have been safely discharged at a lower level of care. Furthermore, the care rendered in the interval between her presentation and subsequent surgery does not rise to the level required of acute inpatient services, and the interval delay itself is not addressed in the medical record. The submitted documentation does not establish the medical necessity of the inpatient admission. 

The health plan correctly identified that the care rendered could have been safely accomplished at a lower level of care as opposed to acute inpatient status. By doing so, the plan acted in a reasonable manner, with sound medical judgement, and in the best interest of the patient.