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 emergency room (ER) with a complaint of 1 month of intermittent severe 7.5/10 abdominal pain after an upper respiratory infection (URI) that lasted a couple of days prior to current presentation. The patient reported nasal congestion, rhinorrhea, sneeze, cough and yellow colored emesis that started several weeks prior to presentation. Approximately 19 days prior to presentation, the patient reported the URI symptoms resolved and non-bloody diarrhea began in the setting of vomiting which remained.
The patient went to another emergency room (ER) several days prior, once symptoms did not resolve. Lab results at that time were significant for erythrocyte sedimentation rate (ESR) 53, C-reactive protein (CRP) 18.8, and lipase 42. The patient had an abdominal ultrasound (US) which revealed hepatic steatosis. The gallbladder was normal, pancreas obscured by gas. He was discharged on Maalox 10 milliliters (mL) every six hours (q6hrs) for indigestion and Famotidine 20 milligram (mg) tablet twice daily (BID) and told to follow up with a gastroenterology (GI) specialist.
The patient was finally able to see a GI specialist where she discontinued his ER medications and instead prescribed omeprazole 20 mg BID.  The patient reported mild improvement in his abdominal pain following the medication change. In office, it was noted that the patient may need esophagogastroduodenoscopy (EGD) /colonoscopy in the future if symptoms persisted. The patient was told that if symptoms persisted, abdominal pain, vomiting and diarrhea continued he should go to the ER so the patient presented to the ER. He typically had diarrhea 3-4 times a day accompanied by vomiting 3-4 times daily, after eating. Both had improved slightly, concerning the volume. The patient reported that his localized abdominal pain was sometimes relieved by passing a bowel movement, drinking water or eating a potato or toast.
The patient had remained afebrile during this time but had lost 5 pounds (lbs) due to the vomiting and diarrhea. He has also missed several weeks of school since the onset of his symptoms. He had 3 episodes of diarrhea since, in the ER, and his last emesis was at 6 PM on the day of admission after taking chicken noodle soup. He denied any chills, constipation, chest pain, palpitations, fatigue, mouth pain or rash.
In the ER, the patient was in moderate distress. Blood pressure (BP) was elevated at 154/91, he was tachycardic to a heart rate (HR) of 111 and respiratory rate (RR) was 20. Temperature was 98.5 degrees Fahrenheit, oxygen saturation (O2 sat) 100% on room air (RA). There was tenderness to palpation of his abdomen. Lab results were unremarkable. A computed tomography (CT) scan of the abdomen showed hepatosplenomegaly. A urine culture was collected. The patient was given a GI cocktail, omeprazole, Zofran and started on intravenous fluids (IVF) before being admitted to the floor for rehydration, pain management and further workup. On the admission exam, he was described as laying comfortably in bed watching utube videos, abdomen with tenderness to the left lower quadrant (LLQ) and left upper quadrant (LUQ). Once admitted to the floor, the patient was in pain which was controlled by Tylenol. He tolerated a regular diet, with no further episodes of emesis or diarrhea. The patient stooled once while inpatient which was collected for stool studies. GI consulted and recommended no acute inpatient interventions and follow up of stool studies outpatient.
At issue is the medical necessity of an inpatient stay.

The requested health service/treatment of inpatient stay is not medically necessary for this patient. His clinical findings described in the medical record, along with his laboratory and physical findings, do not support a diagnosis of dehydration or a surgical abdomen requiring emergent intervention. There was no mention of a failed PO trial in the pediatric emergency room. There is no documentation that the patient had poor PO intake associated with his intermittent vomiting. At the outset, a CT scan of the abdomen did not reveal any emergent condition that would require inpatient level of care. He had stable vital signs apart from an elevated blood pressure in the ER that normalized quickly, essentially normal laboratory and non-emergent radiological findings, therefore deterioration or the need for highly specialized or skilled care would be unlikely in this case. The GI specialist was consulted and did not recommend any acute inpatient management. The patient's abdominal pain was well controlled on PO Tylenol and he had no vomiting or diarrhea after admission. He tolerated a diet well. He could have been managed at a lower level of care.. Inpatient stay was not medically necessary.