Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld.

The patient has hypertension and coronary artery disease (CAD) with stents. The patient presented with abdominal pain. The studies showed a possible bowel obstruction and an elevated white count. The patient did not have a nasogastric tube (NGT) placed. The patient did not fail observation care prior to being admitted as an inpatient. The inpatient admission is under medical necessity review.

Despite the patient's presentation, the care provided could have been rendered in its entirety at a lower level of care. The patient had an infection; yet the patient did not show any evidence of a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for nothing by mouth (NPO) status, need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias, or any other indication for an acute admission. As such, the care could have been given at a lower level of service.      

"Abdominal pain is one of the most common complaints of patients admitted to emergency units, accounting for approximately 4-5% of emergency department visits (1-3). Recent studies show that self-referrals due to abdominal pain, as well as primary care physician referrals to emergency departments, have increased, imposing heavy burdens on emergency surgical care providers (4). Generally, suggesting a rational differential diagnosis and planning a suitable diagnostic and management approach have always been challenging for primary care physicians when treating patients with abdominal pain. One challenging aspect of abdominal pain treatment is the request for appropriate paraclinical diagnostic tests (5). In fact, performing many unnecessary laboratory tests and radiological imaging procedures not only delays the final diagnosis, but also imposes significant costs. Among different body parts, the abdomen and abdominal problems have always intrigued researchers (2). Overlaps in the initial presentations of benign and life-threatening pathologies, nonabdominal source of pain, and presentation of atypical signs and symptoms rather than the classic ones, which may also vary with age, sex, and comorbidities, are among confounding factors for timely and accurate diagnosis of abdominal pain (1, 6). Therefore, examination and management of abdominal pain should start with precise history-taking and complete physical examination, followed by the selection of proper diagnostic laboratory tests and imaging modalities to establish a diagnosis" (1).

"Initial management should always include an assessment of the patient's airway, breathing, and circulation. Nasogastric tube insertion will allow for bowel decompression to relieve distention proximal to the obstruction. Nasogastric tube insertion will also help control emesis, allow for accurate assessment of intake and output, and lower the risk of aspiration. Management ultimately depends on the etiology and severity of the obstruction. Stable patients with partial or low-grade obstruction resolve with nasogastric tube decompression and supportive measures. Complete or high-grade obstructions often require urgent or emergent surgical intervention as the risk of ischemia increases. Chronic disease states such as Crohn's disease and malignancy require initial supportive measures and longer periods of nonoperative management. Treatment will ultimately depend on the patient's disposition and surgeon's acumen" (3).

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for an inpatient admission is not substantiated.