Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive system/Gastrointestinal-abdominal pain.
Treatment: Inpatient Hospital. 
The insurer denied inpatient hospital admission. 
The denial is upheld.

The patient is a female who presented to the emergency department with concerns of abdominal pain, nausea and vomiting. Pertinent history included morbid obesity, migraines, and gestational diabetes. Initial vital signs found the patient to be afebrile and hemodynamically stable. Initial examination documented the patient as alert without focal tenderness. Initial serology revealed a hemoglobin (Hgb) of 10.8, platelets (Plt) of 191, sodium (Na) of 139, potassium (K) of 3.7, blood urea nitrogen (BUN) of 8, creatinine (Cr) of 0.47, alkaline phosphatase (ALP) of 115, aspartate aminotransferase (AST) of 15, alanine aminotransferase (ALT) of 17, total bilirubin (Tbil) of 0.6, lipase of 16, international normalized ratio (INR) was 1.1, and troponin was unremarkable. Electrocardiogram (EKG) did not reveal acute ischemic changes. Computed tomography angiography (CTA) of the chest did not reveal a pulmonary embolism or other acute cardiopulmonary pathology. CT(computed tomography) of the abdomen/pelvis did not reveal acute findings. The patient was admitted thereafter with an impression of viral gastroenteritis, mesenteric lymphadenopathy, normocytic anemia, and migraine. Treatment plan included intravenous fluids and supportive care. The following day the patient continued to note nausea, abdominal pain, and intolerance to oral intake. A fever of 100.7 was noted. Intravenous fluids and anti-emetics were continued. Obstetrics/gynecology (OB/GYN) consultation was obtained who recommended an outpatient endometrial biopsy. The following day, the patient was deemed medically stable and discharged to home.

The subject under review is the medical necessity for the inpatient hospital admission.

The health plan's determination is upheld.

Based on the clinical documentation provided, evidence based literature and standards of care, acute inpatient level of care was not indicated as medically necessary for the entire admission. Evaluation and management could have been performed at a lower level of care.
The patient presented with abdominal pain, nausea and vomiting. She was hemodynamically stable on arrival and throughout the hospital stay. Examination did not reveal acute peritoneal signs. An extensive evaluation was performed which did not reveal an acute intraabdominal pathological process. Treatment plan included intravenous fluids, analgesia, and anti-emetics. No other issues or complications were documented. Following observation care, the patient was deemed medically stable for discharge.
Macaluso et al. note abdominal pain is the most common reason for a visit to the emergency department. Although a common presentation, abdominal pain must be approached in a serious manner, as it is often a symptom of serious disease and misdiagnosis may occur. 
In regard to level of care, clinical indications for admission to inpatient care were not met. The patient did not have peritoneal signs, evaluation requiring patient to not eat or drink for extended period (more than 24 hours), hemodynamic instability, severe pain requiring acute inpatient management, identification of etiology or finding that requires inpatient care (e.g., aortic dissection, bowel perforation, bowel ischemia), signs of intestinal obstruction, suspected toxic megacolon, bacteremia, severe electrolyte abnormalities requiring inpatient care, inability to maintain oral hydration that persists after observation care treatment, or a surgery needed that cannot be performed at a lower level of care status.