Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal pain
Treatment: Inpatient admission
The inpatient admission was medically necessary.

The patient is a female child with medical history significant for prematurity born at 31 weeks' twin gestation, longstanding intermittent constipation, no bowel movement for a week, and abdominal pain that was referred to the emergency department (ED) from the Gastroenterology (GI) Clinic for evaluation and bowel clean-out.  She had been seen in the ED previously at which time she was given and enema and prescribed Miralax. She was seen in GI Clinic with encopresis and significant stress component. She was prescribed Senna, behavior modification, and referred to Psych. She was refusing to sit on the toilet and had episodes of stool incontinence at school. 

Vital signs included temperature 98.7, hart rate 73, respiratory rate 20, and blood pressure 107/64. Examination was significant for no distress, well-hydrated appearance, moist oral mucosa, clear lungs, soft mildly distended non-tender abdomen, and non-focal neurologic exam. The case was discussed with her Pediatric Gastroenterologist, with recommendations to obtain abdominal x-rays and administer a Fleet enema. The abdominal x-ray revealed moderate amount of stool in the large bowel and rectum with no small bowel dilatation. The Fleet enema was ineffective. Laboratory evaluation revealed normal white blood cell (WBC) count, unremarkable metabolic panel, and mildly elevated phosphorus. A nasogastric tube was placed for GoLYTELY administration. 

The patient was subsequently admitted for bowel clean-out with admitting diagnosis of fecal impaction and constipation. Admitting orders included nothing by mouth, intravenous (IV) fluids, GoLYTELY, enemas as needed, parenteral omeprazole, and social services consultation. The patient began to vomit shortly after the GoLYTELY began, requiring discontinuation. She remained with nothing by mouth on IV fluids. After a period of rest, the GoLYTELY was restarted without difficulty. Additional lab work (thyroid studies) and follow-up metabolic panel were unremarkable. She was able to tolerate two hours of GoLYTELY and one enema productive of two watery stools. She remained on GoLYTELY through the day of discharge, gradually cleaning out her bowels. Repeat abdominal x-ray on the day discharge showed significant improvement, with no significant stool in the rectum. She was passing liquid stools and had no abdominal pain. She was deemed stable for discharge, on Senna and Miralax, to follow-up with Pediatric Gastroenterology and Psychiatry.

In this case, the child failed outpatient management of constipation with an enema, Miralax, and Senna. She presented to the ED with no real stool for a week, abdominal pain, and multiple daily episodes of overflow encopresis. An enema in the ED was ineffective. A nasogastric tube was passed and she was started on GoLYTELY. She initially had vomiting and did not tolerate the GoLYTELY, but over time she was able to tolerate the GoLYTELY in conjunction with enemas and was able to evacuate her bowels. It took several days for complete evacuation and normalization of her abdominal x-ray and abdominal exam. 

This child required aggressive intervention to clean out her bowels, having failed outpatient management, likely due to the persistence and longevity of the problem as well as a significant stress component. Acute inpatient management was reasonable and medically necessary for this child, consistent with the current standard of care as well as management guidelines.