Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient stay
The insurer denied the inpatient stay. 
The health plan's determination is upheld. 

This is a patient with a past medical history significant for hypertension and hyperlipidemia who presented to the emergency department with complaints of abdominal pain, leg pain, and swelling. The patient stated that the abdominal pain began 24 hours before the admission and was associated with nausea without vomiting. The patient had one episode of diarrhea. The patient reported that in the last 6 months before presentation there was noted intermittent lower extremity swelling, which was associated with pain in the legs. The pain was worse when the patient was lying down. It was alleviated by walking. The patient also noted some worsening dyspnea over the course of six months, which became worse lately. The patient became short of breath after walking 5 blocks or climbing a flight of stairs and also reported intermittent sharp chest pain, which was aggravated by exertion and radiated to the back and neck. There was no clear history of orthopnea or paroxysmal nocturnal dyspnea.
While in the emergency department the patient developed a fever up to 38.7C. and her heart rate went up to 115 bpm. Then the fever resolved, and the heart rate normalized. A computed tomography (CT) scan of the abdomen and pelvis demonstrated left-sided broad-based subserosal myoma. There was diverticulosis without evidence of diverticulitis. The patient was admitted to the hospital with a diagnosis of gastritis. Since the patient had an elevated D-dimer, a computed tomography angiography (CTA) of the chest and lower extremity venous duplex ultrasound was ordered. Initially, the patient was placed on an empiric Heparin drip for possible pulmonary embolism. Although once the CT angiogram of the chest did not reveal evidence of pulmonary embolism, the Heparin drip was discontinued. Multiple attempts were made to perform lower extremity duplex and transthoracic echocardiogram, but the patient continued to refuse these procedures over the course of multiple days. During the hospital stay, the patient remained afebrile and had a normal heart rate as well as normal white blood cell count. The abdominal pain resolved, and the patient was discharged home in satisfactory clinical condition.
At issue is the medical necessity of the inpatient stay. No. The inpatient hospital stay was not medically necessary for this patient. This patient presented to the hospital with acute onset of abdominal pain, which most likely represented acute gastroenteritis, which is a self-limited condition. The acute gastroenteritis did not lead to severe dehydration or electrolyte abnormalities. The CT scan of the abdomen and pelvis did not demonstrate any serious medical problems that would necessitate evaluation or treatment at the acute inpatient level of care. Abdominal pain and fever resolved very quickly. Another clinical problem was shortness of breath, which was chronic. The patient was ruled out for serious reasons that could contribute to chest pain. Specifically, the CT scan of the chest was negative for pulmonary embolism and did not reveal any evidence of aortic dissection or aneurysm. Even though the patient complained of some shortness of breath and dyspnea on exertion, there was no evidence that the patient developed acute respiratory failure or required supplemental oxygen. Taking into consideration all these facts, the severity of the patient's condition or the complexity of the services provided in the hospital did not rise to an acute inpatient level of care.