Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain.
Treatment: Inpatient admission.
The insurer denied coverage for inpatient admission.
The denial is upheld.
 
This case involves a female who presented to the hospital complaining of abdominal pain. She had a history of obesity, esophagitis, and posttraumatic stress disorder. At the time of her initial assessment, there were some abnormal laboratory values to include mildly elevated lipase and amylase. Imaging of the abdomen revealed hepatic steatosis whereupon the patient was admitted for care. She was started on Protonix and was seen by gastroenterology. Esophagogastroduodenoscopy revealed mild esophagitis and gastritis. After her diet was advanced, she was discharged home after a period of hemodynamic stability. The hospital stay was denied coverage given that there were no abnormal findings on imaging with a possible inflammation of the pancreas, which improved after treatment. It was determined that the treatment with intravenous fluids, pain medications, and observation could have been completed without the need for inpatient care. An appeal was submitted indicating that because of the complaints of abdominal pain, nausea, and vomiting, and grade D esophagitis noted on esophagogastroduodenoscopy previously with the possibility of acute pancreatitis, the inpatient stay was justified.

The hospital admission was not considered medically necessary for this patient.

The Milliman care guidelines indicate that clinical indications for admission to inpatient care for patients with abdominal pain include those who are hemodynamically unstable, have severe pain requiring acute inpatient management, have peritoneal signs, when there is identification of etiology or findings that require inpatient care such as aortic dissection, bowel perforation, bowel ischemia, visceral organ torsion, or intestinal obstruction, for patients who require an evaluation and are aware not to eat or drink for extended periods of time, (for example more than 24 hours), when they are unable to maintain oral hydration, have suspected toxic megacolon, bacteremia, or needed procedure that cannot be performed on an ambulatory basis. In the case of this patient, records did not support that she met the criteria for inpatient stay and could have received her treatment on an outpatient basis or observational basis. Aside from a slightly elevated blood pressure reading during triage, the patient's vital signs were stable. She had some pain in the epigastric region rated 8/10, with reports of vomiting, and right upper quadrant tenderness on palpation, but with bowel sounds in all 4 quadrants and no diarrhea, change in bowel habits, hematochezia, melena, rectal pain, or stool incontinence. Based upon the provided information, it was determined that the testing conducted to assess for the cause of the patient's symptoms, along with the treatment measures administered, the patient did not require inpatient care. All services could have been rendered on an observational basis or an outpatient basis as there was no evidence of hemodynamic instability or other significant abnormalities that would require inpatient level of care. The prior determination is upheld.

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

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