Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Constipation

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld.

This is the case of a male with a past medical history notable for bilateral inguinal hernia repair that presented to the Emergency Department (ED) with non-bloody diarrhea, fecal soiling, intermittent crampy bilateral lower abdominal and nausea without vomiting for 2 days. He had decreased oral intake. There was no associated fever, gastrointestinal (GI) bleeding, dizziness, weight loss or dysuria. The patient was not taking any medications. Physical exam showed alert male in no apparent distress. There was discomfort to palpation in the lower abdomen without organomegaly, distension, rebound, guarding or masses. Bowel sounds were hypoactive. Rectal exam was notable for hard stool with leakage. Imaging included an abdominal sonogram that failed to show an appendix (a normal finding) and shotty scattered small lymph nodes. An abdominal computed tomography (CT) scan showed a normal appendix with stool distending the ascending colon and rectum and mild rectal wall edema. He received intravenous (IV) fluids. A consultation with pediatric surgery recommended no acute intervention. He received glycerin suppository. A mineral oil Fleet enema was ordered. A consult with pediatric gastroenterology recommended Golytely every 1 hour orally for a total of 10 times, serial exams, repeat chemistries and repeat abdominal x-ray. It is unclear how many of the 1-hour boluses he actually received but passed 2 large stools by the following morning witnessed by the mother. There was no vomiting. He received no pain medications or anti-emetics. Repeat electrolytes remained normal. His diet was advanced and tolerated and he was discharged home for outpatient follow-up. 
 
This child appears to have constipation with overflow incontinence without significant dehydration that resolved with treatment. He did not appear significantly dehydrated on presentation nor did his nausea without vomiting predispose him to an inability to hydrate as suggested in the appeal. According to a review of the approach to 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, significant weight loss, profound lethargy, 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 inpatient setting. 

The documentation of this child's appearance and vitals would indicate that his stool burden could have been managed in the outpatient setting with close follow-up. His lack of dehydration, his ability to tolerate oral treatment and the lack of need for manual disimpaction would predict success in the outpatient setting. One glycerin suppository plus or minus a mineral oil Fleets enema does not constitute a failure of outpatient management as suggested in the appeal. He actually received no acute care after admission to merit reimbursement at that level. He tolerated an oral cathartic regimen that he regulated, was given IV fluids without dehydration or the inability to orally hydrate and he never needed pain medications.

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.