Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain. 
Treatment: Inpatient admission. 

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

The patient is a female teen with medical history of asthma that was referred to the emergency department from Urgent Care for evaluation of right lower quadrant pain, three episodes of vomiting, and two episodes of diarrhea. The pain was described as aching and sharp, moderate in severity, constant and worsening, rated six out of ten. 

Vital signs included temperature 37.9, heart rate 104, respiratory rate 20, and blood pressure 93/57. Examination was significant for moist mucous membranes, tachycardia, tachypnea, tenderness in the right lower quadrant as well as epigastric and periumbilical areas, positive Rovsing's and McBurney's signs, no rebound, and non-focal neurologic exam. Laboratory testing revealed normal white blood cell count with left shift (6.5K with 81% neutrophils), normal carbon dioxide (CO2) (22), normal amylase and lipase (83, 56 respectively), and ketonuria (40). Computed tomography (CT) scan was negative for appendicitis. Her pain persisted rated up to nine out of ten. She was treated with a normal saline bolus, Toradol, and Pepcid. Surgery was consulted with no further recommendations. She was subsequently admitted for serial abdominal examinations, intravenous fluids, and nothing by mouth. 

The following morning the patient denied abdominal pain but had some generalized tenderness to deep palpation. Covid testing was negative. Her diet was advanced to clear liquids and she remained on intravenous fluids. She was able to tolerate regular diet for age with resolution of pain, vomiting, and diarrhea. She remained afebrile for the duration of her hospital stay. She was subsequently deemed stable for discharge to follow-up with her primary care practitioner. 

No, the acute inpatient hospitalization was not medically necessary. 

Acute abdominal pain is a very common complaint in children and teens. The differential diagnosis is quite broad, including infectious causes, structural abnormalities, appendicitis, renal causes such as stones, constipation, behavioral/emotional issues, inflammatory diseases, and diseases associated with malabsorption. History, physical examination findings, lab evaluation, and radiographic studies provide additional clues to the etiology. Radiographic studies include plain x-rays, ultrasound, and computed tomography scan with and without contrast. 

Lower quadrant and suprapubic pain in a female may indicate gastrointestinal, urinary, or gynecologic involvement. The differential diagnosis would include appendicitis, urinary tract infection, endometriosis, ovarian cyst (including rupture and torsion), mittelschmerz, pregnancy, pelvic inflammatory disease, and constipation. 

This female teen presented to the emergency department with severe abdominal pain, nausea, vomiting, and diarrhea. Appendicitis was ruled out with normal abdominal imaging. She was monitored with serial abdominal examinations and treated with intravenous fluids. While it was reasonable to monitor for evolution of abdominal pain and document ability to tolerate fluids by mouth, she was overall hemodynamically stable, with no evidence of impending shock, no evidence of severe dehydration, and no significant underlying medical conditions. She did not require acute inpatient admission and could have been safely managed at a lower level of care like observation. 

Acute inpatient admission was not medically necessary. The patient could have been safely managed at a lower level of care.