Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain
Treatment: Inpatient hospital admission 

The insurer denied coverage for the inpatient hospital admission.
The denial is upheld.

This child with a history of asthma, eczema and obesity presented to the Emergency Department (ED) with right-sided abdominal pain. The pain started 3 days prior along with vomiting and decreased appetite. The patient was seen earlier in the week at the same hospital with similar complaints. Testing at that time showed an unremarkable Covid test, abdominal sonogram and urinalysis. In the ED, her vital signs included a heart rate of 93 beats per minute, temperature of 99.1, respiratory rate of 18 breaths per minute, blood pressure 136/63 and room air oxygen saturation of 95 percent. Physical exam showed mild abdominal distress. She had moist mucus membranes with normal capillary refill and normal skin turgor. Lungs were clear. Cardiac exam was unremarkable. Abdomen exam was soft with tenderness to palpation in the periumbilical region and right lower quadrant. There were no associated organomegaly, distension, rebound, guarding or masses. Bloodwork was normal. Urinalysis was notable for trace ketones. Nasal viral washings were negative. An abdominal computed tomography (CT) scan showed a normal biliary tree/liver, a normal appendix and scattered mesenteric lymph nodes.  She received an intravenous (IV) fluid bolus followed by continuous IV hydration. In addition, she received IV Zofran, IV Toradol and IV Tylenol. Despite a second Zofran dose the patient failed an oral challenge (nausea). She was admitted for intractable vomiting, pain management, hydration, and observation. She remained afebrile throughout the admission. She had no further vomiting during her stay. Her pain was controlled with IV Toradol and oral Motrin. She received a daily dose of Protonix. She was discharged home the day after admission and instructed to follow-up as an outpatient. 
  
This child appears to have had abdominal cramps secondary to viral-induced mesenteric adenitis. She did not appear dehydrated and had no red flags to suggest a serious condition.  In accordance with a review of the approach to emergency  evaluation of acute abdominal pain in children from UptoDate, the reasons to admit such an individual would include signs of significant dehydration poorly responsive to intravenous hydration in the ED, hemodynamic instability, significant electrolyte imbalance, demonstrated oral hydration intolerance to oral challenge, poorly controlled pain with an oral pain medication regimen, concerning physical exam findings for a surgical process or findings consistent with significant blood loss or bowel obstruction. She did not meet any of these criteria to merit the inpatient setting. The evaluation performed prior to admission excluded serious possible causes of her symptoms. Her pain did respond to treatment in the ED with multiple notes documenting pain improvement.  Once admitted her pain was controlled with minimal medications and vomiting did not recur (clearly not intractable).
  
The documentation of this child's appearance and vitals would indicate no dehydration necessitating admission to the hospital for monitoring of strict intake and output. It seems she tolerated the oral contrast for her CT scan prior to admission. Vomiting never occurred throughout the admission with a clear diet and last antiemetics given were 1 hour before the decision to admit her to the inpatient service. After an evaluation excluded dangerous conditions, she could have been observed in the ED and safely discharged on oral pain medications, clear liquids and acid suppression with outpatient follow-up. 

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

Based on the above, the medical necessity for the inpatient hospital admission is not substantiated. The insurer's denial is upheld.