Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain.
Treatment: Inpatient Hospital Stay.

The insurer denied the Inpatient Hospital Stay.  The determination is upheld.

The patient presented to the hospital with complaints of diffuse abdominal pain that started acutely several hours before his presentation. The pain radiated to the back. Upon presentation at the emergency department, he was afebrile and normotensive.
He underwent a computed tomography (CT) scan of the abdomen and pelvis that revealed a partial small bowel obstruction with two transition points in the mid-abdomen with significant gastric distention and relatively decompressed duodenum. The review of systems was negative for fever, chills but positive for a mild headache. The patient denied chest pain, shortness of breath.

When seen by the admitting physician he remained afebrile, the heart rate was 67 beats per minute (bpm), respiratory rate was 18 breaths/minute, blood pressure 108/91, and oxygen saturation 99% on room air. The patient was awake, alert, and in no acute respiratory distress. The head, eyes, ears, nose, throat (HEENT) exam was within normal limits. The neck was supple without lymphadenopathy, masses, jugular vein distention (JVD), carotid bruits. The patient had a regular heart rate and rhythm, without murmurs, rubs, or gallops. The lungs were clear to auscultation without wheezes, rales, or rhonchi.

The abdominal exam revealed mild distention. The abdomen was nontender to palpation. Bowel sounds were present in all four quadrants. The rest of the physical exam was unremarkable.

Laboratory evaluation revealed that white blood cell count was 15.1, hemoglobin 18, hematocrit 51.7, and platelets 255. The sodium was 139, potassium 4.3, chloride 102, bicarbonate 26, blood urea nitrogen (BUN) 17.1, creatinine 0.97, and glucose 109. The Calcium was 10.5 , liver function tests were unremarkable.

The patient was admitted to the hospital with a diagnosis of partial small bowel obstruction. A nasogastric (NG) tube was placed for decompression. The patient was kept nothing by mouth (NPO). Intravenous pain medications and antiemetics were ordered.

Another clinical diagnosis at the time of admission was erythrocytosis. The admitting physician stated that the baseline was unknown. At the time of admission, the patient was also diagnosed with hypercalcemia. It was mentioned that treatment with intravenous fluids was initiated, with the plan to recheck red blood cell count and serum calcium levels in the morning.

During the hospital stay, the patient was seen by the surgical service. It was confirmed that the patient had a partial small bowel obstruction. Conservative treatment with intravenous fluids, NG tube decompression, and bowel rest was recommended. During the hospital stay, the patient's clinical condition started to improve. This allowed clamping of the NG tube, which subsequently was removed.

When the patient's symptoms started to improve, a clear liquid diet was initiated, and the patient tolerated it without difficulties. The patient had no difficulties with ambulation. Since the patient's clinical condition continued to improve, he was discharged.

At issue is the medical necessity of an inpatient stay.

The hospital stay was not medically necessary for this patient at the acute inpatient level of care.

There was no compelling clinical reason why the patient could not have safely and appropriately received evaluation and treatment at the observation level of care with subsequent transition to outpatient care, rather than admission to an inpatient level of care. Overall, this patient remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care.

The review of the medical records demonstrated that the patient had a partial small bowel obstruction that was not associated with severe pain, feculent vomiting, significant electrolyte abnormalities, or bowel ischemia. There was no evidence of bowel perforation. The NG tube remained in place for a short period of time and was clamped on the next day after the day of admission while the trial of clear liquids was initiated. The small bowel obstruction was not associated with systemic symptoms and resolved relatively quickly.

Therefore, a lower level of care was the most appropriate, considering the fast resolution and lack of significant complications related to the small bowel obstruction.
The small bowel obstruction resolved relatively quickly and was not associated with severe pain, intractable vomiting, or other complications requiring diagnostic procedures or interventions necessitating admission at the acute inpatient level of care. The hospital stay was relatively short and care could have been provided at a lower level than inpatient.