Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain. 
Treatment: Inpatient admission. 

The insurer denied coverage for an inpatient admission. 
The denial is upheld. 

According to the medical records, the member is a female patient with a history of sleeve gastrectomy. The patient presented to the emergency department (ED) with a complaint of abdominal pain in the left lower quadrant (LLQ) associated with nausea and emesis one time, and with pain that worsened with food ingestion. The patient reported the pain around the belly button area, was sharp and rated 7 out of 10. The examination noted tenderness with palpation to the LLQ. The abdomen was soft and non-tender, with bowel sounds normal in all four quadrants. Laboratory results were within normal limits. A urinalysis noted trace protein and trace ketones. The computed tomography (CT) scan showed post sleeve gastrectomy, with no gastric leak or obstruction present. The appendix was normal in appearance, and there was a 2.2 centimeters (cm) ovary corpus luteum cyst with a small amount of pelvic fluid. There was also a fibroid uterus measuring 8.3 x 7.7 x 6.5 cm. Otherwise the CT was unremarkable. 

Despite the patient's presentation, the care as provided could have been rendered in its entirety at a lower level of care. The patient had abdominal pain with nausea and emesis, yet she did not have any evidence of a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, or renal abnormalities. There was no need to be nothing by mouth (NPO) status, or a 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 rendered at a lesser level. There is no cogent medical literature to mandate an inpatient admission for this patient. 

Stable asymptomatic patients can be discharged from an emergency room. Discharge criteria may include: 

- Asymptomatic 
- No abnormal clinical features 
- Normal vital signs 
- Tolerate oral intake 
- Adequate social support at home 
- Patients should be given proper diet advice and safety instructions." (Mehta 2016). 

"The majority of complications associated with VSG (vertical sleeve gastrectomy) occur in the late postoperative period. These include gastroesophageal reflux (23%), vomiting (18%), gastric tube stricture (2.3%; Figure 5), stenosis (2.4%), leak (2.4%),
incisional hernia (2.4%), gastrocutaneous fistula, and weight regain.19,23,24 Although the main mechanism of VSG is restriction, it has been reported that the gastric tube may dilate over time, or it may simply dilate as a result of being overly large. A neofundus (proximal dilation of the stomach) may form if too much fundus is left at the time of the original operation.24,26,27 The dilation of the gastric tube or stomach may be an anatomic reason for the lack of weight loss or weight regain, as patients are able to consume larger volumes of food. In addition, the neofundus can cause, or be the result of, relative midstomach stenosis with subsequent food stasis that contributes to symptoms of gastroesophageal reflux.24" (Ma et al., 2015). 

"Patients who have had a sleeve gastrectomy may suffer from gastric leak, gastric stenosis, or gastroesophageal reflux." (Lewis et al. 2016).                                                  

The health plan acted reasonably with sound medical judgment in the best interest of the patient. 

The insurer's denial of coverage for the inpatient admission is upheld. Medical Necessity is not substantiated.