Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld
 
Patient with past medical history of Crohn's disease and depression that was transferred to the Emergency Department (ED) for management of abdominal pain x 1 day associated with nausea without vomiting and decreased appetite. The patient had been treated with intravenous (IV) Toradol and morphine, and one liter of normal saline prior to transfer. There were no associated fevers, dysuria, fatigue or weight loss. Nasal viral washings were positive for parainfluenza. Imaging included an abdominal computed tomography (CT) scan with oral contrast showing thickened jejunal loops (poorly distended or inflamed), a normal appendix, scattered mesenteric lymph nodes and mild splenomegaly. An abdominal and pelvic sonogram one day after admission showed splenomegaly but were otherwise unremarkable. She received two additional 4 milligram (mg) IV doses of morphine as well as IV Zofran 4mg. She was admitted for bowel rest, pain management and monitoring. While admitted she had pain on and off responsive to two additional IV doses of morphine and oral Tylenol thereafter. She vomited once during the admission and receive one additional IV dose of Zofran the day after admission and oral Zofran thereafter. A gastroenterology consult recommended stool studies, oral Flagyl and oral Pepcid. Her stool studies showed negative cultures, calprotectin 224, negative clostridium difficile and negative occult blood. Repeat labs were unremarkable and a repeat urinalysis was negative. She was discharged home despite continuing to complain of nausea. She remained afebrile the entire admission. She had a number of loose stools during the admission (after patient had received oral contrast).  

This teenager appears to have abdominal pain and loose stool most consistent with a viral process. Her pain was clearly different from her prior Crohn's flares and her finding on imaging did not coincide with her exam findings. She was not dehydrated, had vomited once the entire admission and had no abdominal distention. In accordance with a review of the approach to the 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 IV 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 acute inpatient setting. The fact that IV morphine was given did not suggest that an oral pain regimen would have failed to control symptoms. In fact, no IV pain medications were administered after the second day of admission. 
 
This teenager lacked fever, had a favorable physical exam, reassuring laboratories and lacked localizing imaging that excluded many serious conditions causing abdominal pain. She certainly did not have intractable vomiting as stated in the appeal. It appears that the decision to admit her was based more on the fact that she had been transferred from an outside center rather than for her presenting condition. She had no symptoms to suggest a urinary tract infection and the findings on the first urinalysis contained moderate epithelial cells suggesting a non-clean catch sample. Despite lack of evidence for a Crohn's flare she received oral antibiotics starting the day of discharge. Given these facts continued admission beyond the second day of admission was not medically necessary. 

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

The insurer's denial of coverage for inpatient admission is upheld. Medical Necessity is not substantiated.