Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal 
Treatment: Inpatient Hospital 

This is a patient with a past medical history significant for atrial fibrillation, tobacco use, and micro-hematuria who presented to the emergency department with a 2-day history of abdominal pain, black stools. His abdominal pain was located in the right lower quadrant. The patient denied nausea, vomiting, diarrhea, urinary symptoms, chest pain, and difficulty breathing. 

In the emergency department, the patient was found to be anemic. His stool tested positive for occult blood. Therefore, the patient was admitted to the hospital for further evaluation. The patient was in no acute distress. The head, eyes, ears, neck, throat (HEENT) exam was unremarkable. The neck was supple and lung exam was unremarkable. The cardiac exam was also unremarkable. His abdomen was soft, with mild right lower quadrant tenderness. Bowel sounds were present in all four quadrants; there was no guarding or rebound tenderness. There was no costovertebral angle (CVA) tenderness. The rest of the physical exam was unremarkable. 

Laboratory evaluation revealed that white blood cell count was 4.8, hemoglobin 8.5, hematocrit 25.7, and platelets 151. Sodium was 144, potassium 4.0, chloride 108, bicarbonate 25, blood urea nitrogen (BUN) 27.9, creatinine 0.76, and glucose 106. A urinalysis was unremarkable. 

The patient underwent a computed tomography (CT) scan of the abdomen and pelvis, which demonstrated a normal appendix and findings consistent with ankylosing spondylitis. The patient was admitted to the hospital with a diagnosis of right lower quadrant abdominal pain, acute blood loss anemia secondary to gastrointestinal bleeding. He was started on proton pump inhibitors and received hydration with intravenous fluids. The gastroenterology service was consulted. 

In the hospital, the patient was seen by a gastroenterologist and underwent an esophagogastroduodenoscopy (EGD) on the day of admission. It revealed normal esophagus, nonbleeding gastric ulcers with a clean ulcer base that was biopsied. Erythematous duodenopathy was also reported. The rest of the exam was unremarkable. The gastroenterologist recommended to advance the diet as tolerated, initiate treatment with proton pump inhibitors, await the pathology results, and follow up with the gastroenterologist as an outpatient. 

The health plan's determination is upheld. 

The requested health service/treatment of inpatient hospital stay was not medically necessary for this patient, considering his overall stability, lack of evidence that the patient had acute upper gastrointestinal bleeding based on the results of the EGD, relatively stable H&H level, or presence of any other serious condition that would contribute to his abdominal pain. Even though the patient had abdominal pain, there was no clinical reason that it was associated with a serious medical problem that would require any surgical intervention. Neither the results of the physical exam nor the results of the laboratory studies pointed toward a surgical emergency or conditions that would require complete bowel rest, prolonged administration of intravenous fluids, administration of intravenous antibiotics. 

Although the laboratory evaluation demonstrated that the patient was anemic, there was no evidence of hemodynamic instability, continuous blood loss, hemolysis, acute cardiac ischemia, or peripheral ischemia. The patient underwent the EGD on the day of admission, which did not demonstrate any evidence of active bleeding. His hemoglobin and hematocrit (H&H) remained stable throughout the entire hospitalization. Taking into consideration all of this information, the care could have been provided at a lower level than inpatient.