Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Colitis 
 
Treatment: Inpatient hospital admission 

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

This patient is a male with a history of an immune deficiency disorder. He presented to the Emergency Department (ED) with a 2-day history of abdominal pain, nausea and vomiting, as well as a loss of appetite on the day of presentation. As per the ED history and physical, the patient presented with a 2-day history of abdominal pain associated with nausea and vomiting x 1. The patient had a loss of appetite and had right lower quadrant (RLQ) pain. On exam, he was afebrile with the abdomen being soft with no masses palpable. There was RLQ tenderness without rebound or guarding. The patient was admitted for early appendicitis. The white blood cell (WBC) count was 4.31 and a CT revealed borderline appendiceal thickening with cecal wall thickening which may represent focal colitis. The patient was admitted to General Surgery for further management, including nothing by mouth (NPO) status, intravenous (IV) fluids, IV antibiotics, and serial exams. A progress note revealed the patient had mild tenderness to palpation in the RLQ. He continued to be afebrile. Another progress note revealed the patient denied abdominal pain or discomfort. The abdomen was soft to touch. He had a bowel movement. The IV fluids were discontinued and the patient was discharged. 

Based upon the records provided, the patient did not require acute inpatient admission as the patient could have been cared for based upon an observation status. According to MCG, Inpatient and Surgical Care, 23rd Edition, Abdominal Pain, Undiagnosed ORG: M-05 (ISC), admission may be indicated for 1 or more of the following: Surgery needed that cannot be performed on ambulatory basis; Peritoneal signs present; Evaluation requires patient to not eat or drink for extended period (e.g., more than 24 hours); Hemodynamic instability;  Severe pain requiring acute inpatient management; Identification of etiology or finding that requires inpatient care (e.g., aortic dissection, free air, bowel ischemia, visceral organ torsion); Signs of intestinal obstruction; Suspected toxic megacolon; Bacteremia; Severe electrolyte abnormalities requiring inpatient care; Inability to maintain oral hydration (e.g. needs IV fluid support) that persists after emergency department and observation care treatment; Percutaneous or open drainage (e.g., abscess, biliary tract) procedures; Parenteral nutrition regimen that must be implemented on inpatient basis; other condition, treatment, or monitoring requiring inpatient admission.  The goal length of stay is ambulatory or 1 day. 

In this case, there was no indication for admission given the guidelines above as this patient could have been treated in ambulatory/observation status. The patient did not have hemodynamic instability or severe pain requiring acute inpatient management. The patient was seen and admitted. By the following day he was improving and had a bowel movement. The patient was kept NPO, but did not have vomiting in the hospital. On the day after, he was given a diet and discharged to home. The patient did not have persistent vomiting, was not dehydrated, and could have been treated with antibiotics for apparent colitis. The patient did not have peritoneal signs and was improving with conservative care; therefore, he could have been treated on an observation status and discharged to home. The patient did not have appendicitis, but a focal colitis as based upon the CT of the abdomen. 

The inpatient hospital admission was not medically necessary at the acute care level and the denial is upheld. The patient could have been placed on an observation status. The insurer acted reasonably, with sound medical judgment, and in the patient's best interest. 

Based on the above, the medical necessity for the inpatient hospital admission is not substantiated.  The insurer's denial is upheld.