Appeal type: Medical necessity
Decision: Upheld

Diagnosis: acute abdominal pain

Treatment is an inpatient admission 

The insurer denied coverage for an inpatient admission 
 
The denial is upheld

The patient with a past medical history notable for elevated cholesterol and obesity, presented to the Emergency Department for assessment and management of abdominal pain for 2-3 days associated with headache. The right lower quadrant pain was intermittent occurring 30 minutes after meals but was becoming more constant. There was no radiation, fever, nausea, vomiting, diarrhea, constipation or bleeding. The patient's vitals on arrival were notable for Temperature 37.1 C (Celsius), Heart Rate 89, Respiratory Rate 16, Blood Pressure 124/67 and room air oxygen saturation of 98%. Admitting weight was 78.4 kilograms. A physical exam showed an awake and alert male in no apparent distress. He had moist mucus membranes with normal capillary refill and normal skin turgor. His lungs were clear with normal effort. A cardiac exam was unremarkable. An abdominal exam was soft with tenderness to palpation in the right lower quadrant with rebound and guarding. There was no associated organomegaly, distension, rebound, or masses. There was no rectal exam reported. 

Laboratories were notable for sodium 139, potassium 3.7, bicarbonate 25, BUN (blood urea nitrogen) 15, creatinine 0.81, glucose 83, white blood cell 10.4 without a left shift (neutrophils 54%, no bands), hemoglobin 14.5, platelet 264 and CRP (c-reactive protein) 1. A urinalysis showed specific gravity 1.026, pH (potential of hydrogen) 7 and dip negative. Nasal viral washings were negative for influenza A, B and COVID-19. An abdominal sonogram showed a borderline enlarged 6 mm (millimeter) appendix without fluid collections - equivocal for appendicitis. He received D(dextrose)5 normal saline at 75cc (cubic centimeters)/hour intravenous (IV) without a bolus. No pain medications were given. 

A surgical consult noted the imaging, reduced pain from 5-7/10 to 2/10 intensity, the absence of rebound/guarding and lack of symptoms consistent with acute appendicitis. The surgeons recommended IV fluids, nothing by mouth and serial abdominal exams. Repeat laboratories 10 hours after the initial set were again unremarkable. An abdominal x-ray was unremarkable. He tolerated a diet and hydration once permitted. 

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 intravenous hydration in the Emergency Department, 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. He did not meet any of these criteria to merit the acute inpatient setting. The fact that a single examiner noted rebound and guarding (when no others did soon after) and that the imaging was equivocal may have merited a period of observation but not the acute inpatient setting. The appeal cited severe pain as justification from the guidelines referenced that was not present.
 
This patient lacked fever, had a favorable physical exam, reassuring laboratories and lacked localizing imaging that excluded many serious conditions causing abdominal pain. He was not dehydrated and did not have significant pain requiring treatment. It appears that the decision to admit him was for observation without intervention. The patient was discharged within hours of admission to the inpatient setting (on the same day) and less than 24 hours after presentation. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient admission services is not substantiated.