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 female with no significant past medical history. She presented to the emergency medical services of the hospital with a complaint of generalized abdominal pain and emesis for 10 days, along with hives. The emesis was described as dark green, which would be consistent with bilious emesis. Hives were located on her right cheek abdomen and right inner thigh. 

The patient was seen in the emergency room and admitted to the hospital. She had documented episodes of vomiting the emergency department. Lab work, x-ray, and ultrasound were obtained. She had tachycardia, with heart rate of 115. Her lab work included evidence of acute inflammation with an elevated C-reactive protein. She had ultrasound which could not rule out appendicitis at the time she was admitted to the floor. 

The patient was given intravenous fluid in the form of 2 boluses Benadryl and Zofran. She had relief of her abdominal nausea and was improved clinically. She was admitted to the floor, and hydration was continued. A CT (computed tomography) scan of her abdomen and pelvis showed no evidence of appendicitis, acute inflammation but did show an umbilical hernia. She was advanced on her diet and was well enough to go home. 

The health plan's reason for the prior denial of coverage for the admission was that the child did not meet inpatient criteria. She was adequately hydrated in the emergency room, and nausea had subsided. The reason for the appeal is that the treating doctors believe that she was inadequately resuscitated in the emergency room and needed continued hydration in the inpatient setting. They also note that the etiology of her abdominal pain and dehydration was not ascertained with the imaging modalities completed in the emergency room, and that further inpatient work-up was appropriate.

Yes, the Inpatient admission was medically necessary. 

While retrospectively it is evidenced that there was resolution of the patient's abdominal pain and the hydration status was improved, in a careful review of the chart, taking into account the information known at the time of admission, there was evidence that the child was still dehydrated when she was admitted. She also did not have the etiology of her bilious vomiting ascertained.  Bilious vomiting and vomiting for seven days are worrisome signs for acute inflammatory or ischemic changes to the intestine that need urgent intervention. There were also lab values, including CRP (C-reactive protein), which point to a possible life threatening inflammatory or ischemic etiology for the bilious vomiting. 

The continued IVF (intravenous fluids), the CT (computed tomography) scan, and the serial exams all were completed to continue rehydration and to rule out acute intestinal ischemia before discharging home.  The treatment completed was reasonable and medically necessary. 

The admission to continue resuscitating the patient while obtaining tests to rule out urgent causes of bilious vomiting and inflammatory changes that were present on admission was medically necessary. 

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient. In real time, the admission was warranted. 
Knowledge of the data present at the time the patient is admitted to the hospital is important. Hydrating the child further allowed safer administration of IV (intravenous) contrasts for the CT (computed tomography) scan.