Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld
 

This is the case of a patient who as per the triage note presented to the emergency department (ED) with abdominal pain. The patient was sent in by her primary care physician (PCP) for small bowel obstruction (SBO) and intussusception. She was afebrile with stable vital signs. The patient stated she complained of lower abdominal pain for 10 days and saw her PCP yesterday who sent her for an outpatient computed tomography (CT) this morning. The patient stated she was called and was told she had a partial blockage and intussusception. She denied fever and chills but did complain of nausea and vomiting. The ED provider note indicated the patient presented with crampy abdominal pain, moderate in severity, and diffuse without radiation. The patient had some vomiting and loose bowel movements. The CT showed small bowel intussusception. An exam revealed the abdomen to be soft, non-distended without rebound or guarding. Labs revealed normal amylase, and white blood cells (WBC) of 7.5. CT of the abdomen revealed no evidence of acute visceral pathology. General surgery was consulted for possible intussusception.

The general surgery consult noted the history as well as the CT which showed possible intussusception at the mid abdomen. An exam revealed mild tenderness to palpation of the abdomen, periumbilical without rebound or guarding. The plan was no surgical intervention, a GI (gastrointestinal) evaluation and to advance diet as tolerated. 

The surgery progress note indicated stable vital signs and a repeat CT showing no intussusception. The plan was to keep the patient nothing by mouth (NPO). 

Progress notes indicated Gastroenterology (GI) was to see the patient. An abdominal x ray showed oral contrast to the level of the distal descending colon. GI recommended an outpatient follow up with a GI workup and GI series as an outpatient.

The patient was discharged later that day.

Based upon the records, the full inpatient admission was not justified as this patient could have been managed as noted by the insurer in an ambulatory/observation setting. She presented for abdominal pain and there was question of a intussusception shown on an outside CT which was not seen on the inpatient CT. She did not need any inpatient admission but rather observation. 

MCG (Milliman Care Guidelines) Health Inpatient and Surgical care 26th edition Intussusception reduction surgical ORG: P-210 (ISC) noted that Clinical Indications for Procedure includes: Failure of outpatient radiologic reduction; Absolute or relative contraindication to radiologic reduction (shock, peritoneal signs, radiographic evidence of intestinal perforation); Suspected pathologic lead point (Meckel diverticulum, polyps); Recurrent intussusception. This patient did not have intussusception on the CT at the hospital and therefore did not require any surgical intervention even if one was to state that this was the reason for full admission. Thus, full hospital admission was not warranted. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the full hospital admission is not substantiated.