Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal pain 
Treatment: Inpatient admission 

The insurer denied the inpatient admission. The denial is overturned. 

Yes, the inpatient admission was medically necessary. 

The patient is a female teen with unremarkable past medical history that presented to the ED in the middle of the night after being awakened from sleep by severe abdominal pain. The pain began in the periumbilical region, described as burning, rated eight out of ten (8/10), spreading diffusely in the umbilical and hypogastric regions. She had no fevers, vomiting, diarrhea, or urinary symptoms. 

Vital signs included temperature 37.1, heart rate 83 respiratory rate 19, and blood pressure 94/61. Physical examination was significant for no acute distress, diffuse abdominal tenderness mainly in the periumbilical and hypogastric region, pallor, and non-focal neurologic exam. Urinalysis was obtained and was negative. Comprehensive metabolic panel and complete blood count (CBC) were unremarkable. She was treated with famotidine and a normal saline bolus. Because of persistent pain, she was given a dose of Toradol, with slight improvement in pain to six out of ten (6/10). Abdominal x-ray was obtained, revealing mild to moderate gaseous distention of bowel loops without significant bowel obstruction. About an hour after administration of Toradol, her pain had resolved and she was able to sleep. Because of concerns for stool impaction on x-ray, an enema was administered, with resurgence of pain to seven out of ten (7/10). Computed tomography (CT) with oral and intravenous (IV) contrast was then performed, revealing gallbladder wall thickening versus mild pericholecystic fluid, no gallstones, and normal appendix. Right upper quadrant ultrasound was obtained revealing possible contracted gallbladder. Surgery was consulted, did not think surgery was indicated, rather thought the issue was constipation. Recommendations included an oral challenge, which resulted in complaints of right upper quadrant pain. 

The patient was subsequently admitted to the pediatric floor for management of intractable abdominal pain and work-up suspicious for acute cholecystitis. Admission orders included nothing by mouth, IV fluids, parenteral Zantac, Tylenol/ibuprofen for fever, and consideration for small bowel follow-through as requested by Surgery. A consult was also placed with Pediatric Gastroenterology, with recommendations to observe, no interventions needed. The patient improved by the second hospital day, with no pain and no tenderness. She was deemed stable for discharge to follow-up with her pediatrician in two to three days and Pediatric GI in two weeks. She was counseled to avoid fatty foods and fast foods for two weeks to prevent any gallbladder pain. 

Acute abdominal pain is a very common complaint in children and teens. The differential diagnosis is quite broad, including infectious causes, structural abnormalities, renal causes such as stones, constipation, behavioral/emotional issues, inflammatory diseases, and diseases associated with malabsorption. History, physical examination findings, lab evaluation, and radiographic studies provide additional clues to the etiology. Radiographic studies include plain x-rays, ultrasound, and CT scan with and without contrast. 
 
In the female patient, abdominal pain may indicate gastrointestinal, urinary, or gynecologic involvement. The differential diagnosis would include appendicitis, urinary tract infection, endometriosis, ovarian cyst (including rupture and torsion), pregnancy, pelvic inflammatory disease, and constipation. 

This female teen presented with severe acute abdominal pain that was refractory to multiple interventions in the ED, including Toradol, enema for disimpaction, IV fluids, an oral fluid challenge, and famotidine. Studies were suspicious for gallbladder disease, but not classic. Pediatric Surgery and Pediatric Gastroenterology was both consulted, each with recommendations to monitor for exacerbation or resolution of pain. In this case, her pain resolved and she was able to be discharged home. The hospitalization was medically necessary because she failed aggressive treatment in the ED, with persistent pain over the course of several hours.