Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal Pain
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned.

The patient is a woman. She presented to the ED (emergency department) with a history of progressively worsening abdominal pain over a period of one day. She has a history of hypertension, hypothyroidism, obesity, prior lap band surgery and subsequent removal of the lap band. Evaluation included physical exam, labs, and CT (computed tomography) scan.

The patient was without fever at the time of presentation. The heart rate was 96 beats per minute. She was tender in the abdomen. Lab data identified an elevated WBC (white blood cell) count of 14.7 K (thousand). CT scan identified pericolonic inflammatory change in the area of the cecum. The differential diagnosis included inflammatory bowel disease and appendicitis. Treatment was initiated with IV (intravenous) fluid and antibiotics. Surgical consultation was obtained.

The patient was admitted to the hospital. She was treated with parenteral antibiotics for the presumptive diagnosis of inflammatory bowel disease. Due to the leukocytosis, worsening pain, and potential for further clinical deterioration, it was anticipated that her stay would be greater than two nights.

The patient was continued with IV antibiotics and MR (magnetic resonance) enterography was planned. She had several episodes of watery stool and stool studies were sent. Crohn's disease was thought to be the etiology of her condition.

Day 2, gastroenterology consultation was requested. She was provided a clear liquid diet. The MRI (magnetic resonance imaging) interpretation was that of inflammation and thickening of the appendix consistent with appendicitis.

Day 3, the WBC count was normalized. The patient was now locally tender in the right lower abdomen. The surgical service re-evaluation yielded the recommendation for appendectomy.

The patient underwent appendectomy on day 4. The operative dictation describes an uncomplicated appendectomy procedure. The patient tolerated the surgical procedure well and was considered to be stable for discharge from the hospital following an initial recovery period.

Yes, the inpatient admission was medically necessary.

The submitted clinical documentation does support the medical necessity of inpatient admission. The patient presented to the hospital with generalized abdominal pain, a leukocytosis, and imaging findings that raised clinical concern for inflammatory bowel disease (Crohn's disease). She required provision of IV antibiotics, surgical consultation and gastroenterology consultation. She was appropriately treated and managed with follow up abdominal imaging and serial abdominal examination. At the time of initial presentation and due to the leukocytosis, worsening pain, and potential for further clinical deterioration, it was anticipated that her stay would be greater than two nights.

Re-evaluation based on additional imaging results (MRI and repeat CT scan) in addition to evolution of the abdominal examination that now demonstrated localized pain in the right lower abdomen yielded a change in the suspected etiology of her abdominal pain to that of appendicitis. The patient underwent appendectomy and was subsequently discharged from the hospital.

The patient had an intra-abdominal infection; she required IV antibiotics, serial imaging, and abdominal examination over a period of greater than two nights. The care and treatment provided was most appropriately provided with an inpatient level of care.

Acute inpatient admission was medically necessary for this patient.

This patient presented with generalized abdominal pain. Evaluation with examination, lab data, and CT scan indicated an inflammatory process in the right lower quadrant. The differential diagnosis included inflammatory bowel disease and appendicitis. Given this patient's prior history of abdominal pain, the clinical concern was for inflammatory bowel disease.

The initial treatment appropriately included NPO (nothing by mouth) status, IV fluid, and IV antibiotics. She was appropriately evaluated with serial clinical examination and additional abdominal imaging. There was an evolution of the abdominal examination that now demonstrated localized pain in the right lower abdomen, yielding a change in the suspected etiology of her abdominal pain to that of appendicitis.

The submitted clinical documentation does support the need for inpatient admission for this patient. The patient required urgent surgical evaluation, follow up lab data, follow up imaging, provision of IV antibiotics, and IV fluid during the initial period of NPO status, and coordination of care by multiple medical specialties. It was anticipated that this treatment would span a period of greater than 48-hours. Inpatient care is indicated in the setting of peritoneal signs or other signs or symptoms of acute abdominal disease. In this case, the patient had significant abdominal pain and tenderness at the time of presentation and was found to have an intra-abdominal infection. Inpatient care was medically necessary for this patient on the specified dates in order to provide the prescribed therapy with parenteral medication and close follow up, given the possibility of clinical deterioration.

Based on the submitted clinical data, the inpatient admission was medically necessary. In this case, the patient presented with an acute intra-abdominal infectious condition that was initially of uncertain etiology. An inpatient level of care was appropriate, medically necessary, and supported by the medical records and medical standards in this case.