Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Abdominal Pain, Vomiting.
Treatment:  Inpatient Hospital Stay.

The insurer denied the Inpatient Hospital Stay.  The determination is upheld.

The patient has a medical history of Crohn's disease. He presented to the emergency department with bilateral upper abdominal pain and right flank pain for one day, as well as vomiting. He had recently been admitted for Crohn's disease flare with likely Henoch-Schonlein purpura, and findings of gastric and duodenal ulcers, and gastrointestinal bleeding. He had recently been changed from infliximab to Stelara. His vital signs were unremarkable. The physical examination was notable for a soft, nondistended abdomen with right upper quadrant tenderness. 

An ultrasound of the abdomen showed no sonographic evidence of cholelithiasis or acute cholecystitis, no biliary dilation, and no hydronephrosis; there was splenomegaly. A urinalysis showed moderate hemoglobin in 10-25 red blood cells per high-power field. A computed tomography scan of the abdomen and pelvis showed wall thickening of the third and fourth portions of the duodenum, which is nonspecific, no evidence of acute appendicitis, no renal or ureteral stones or hydronephrosis, and borderline enlarged spleen. He was treated with intravenous fluids, Solu-Medrol, ondansetron, pantoprazole, morphine, and oral acetaminophen. He was made nil per os. A gastroenterology consultation concluded that he had Crohn's disease with a palpable petechial rash on the lower extremities and hematuria; the recommendation was rheumatology consultation for likely Henoch-Schonlein purpura and pain, increase Stelara dose to every 4 weeks, intravenous Solu-Medrol, nephrology consultation for hematuria and history of elevated blood pressure, and dermatology consultation for possible biopsy.

The rheumatology consultation concluded that he did not require any further testing or treatment from a rheumatologic standpoint, but biopsy was recommended if the rash changes. Dermatology consultation concluded that he had small vessel vasculitis (leukocytoclastic vasculitis) secondary to underlying inflammatory bowel disease versus immunoglobulin (Ig) A vasculitis such as Henoch-Schonlein purpura; vasculitis was not active, and biopsies were deferred, with a recommendation for serial urinalyses to assess for renal involvement, continued treatment of Crohn's disease, and outpatient Dermatology follow-up. He reported one episode of emesis after trying a diet, and mild pain; the skin lesions were improving. He was changed to oral prednisone. He was discharged on prednisone and omeprazole, with a plan for gastroenterology, dermatology, and rheumatology follow-up. At issue is the medical necessity for the inpatient level of care.

The inpatient level of care was not medically necessary. The patient presented with symptoms (abdominal pain, vomiting) and imaging suggestive of Crohn's disease flare. However, there was no complication such as intra-abdominal abscess, bowel perforation, toxic megacolon, peritonitis, fistula, or sepsis, which would require the inpatient level of care. His symptoms quickly improved with conservative management and corticosteroid therapy, and his diet was gradually advanced. Evaluation for dermatologic disease and rheumatologic disease such as Henoch-Schonlein purpura was not conclusive, but outpatient follow-up was ultimately recommended. The interventions performed, including labs, monitoring, imaging, specialist consultations, and corticosteroid therapy could have been performed without the inpatient level of care, at a lower level of care.