Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal/Abdominal Pain. 
Treatment: Inpatient Admission. 
The health plan denied the requested inpatient stay as not medically necessary. 
The health plan's determination is upheld. 

The patient is a female with a past medical history significant for polysubstance abuse, schizophrenia, and bipolar disorder who presented to the emergency department with complaints of intractable left lower quadrant abdominal pain as well as left lower extremity pain. 
She reported that she was a pedestrian that was struck by a vehicle. However, the pain started just a week before her presentation. The patient reported nausea, vomiting, and shortness of breath, which were associated with the pain. She stated that the pain caused difficulties with ambulation for one week. The patient also complained of back pain. The patient stated that she was able to use the bathroom without difficulties and denied paresthesias. 
Given the patient's complaints of abdominal pain, she underwent a computed tomography (CT) scan of the abdomen and pelvis, which revealed a 1.8 cm (centimeter) left adrenal hypodense lesion with diffuse left adrenal gland thickening that appeared unchanged from the previous studies. The CT scan of the abdomen revealed diverticulosis without CT evidence of acute diverticulitis. Her pregnancy test was negative. 

The patient was admitted to the hospital and was diagnosed with left lower quadrant abdominal pain and left lower extremity pain. The admitting physician stated that the patient had a history of polysubstance abuse including cocaine. Therefore, the pain could be of ischemic etiology. However, it was noted that the imaging studies were not suggestive of that, and there was no elevation in lactate levels. Regardless, the patient received treatment with intravenous fluids and antibiotics. She was also started on muscle relaxants and Gabapentin. 
During the hospital stay, the patient underwent an x-ray of the left tibia and fibula. It demonstrated a fracture of the lateral tibial spine, which became mildly displaced compared to prior exams. There were no acute fractures or other findings. X-rays of the pelvis and left hip were unremarkable. In the hospital, the patient underwent a transvaginal ultrasound, which revealed no sonographic evidence of gynecological pathology. 
During the entire hospital stay, the patient remained afebrile and hemodynamically stable. She was discharged from the hospital with a recommendation to follow up with a urologist and endocrinologist due to the adrenal lesion that was identified on the CT scan of the abdomen and pelvis. 
At issue is the medical necessity for the inpatient stay. 

I uphold, on whole, the health plan's determination of medical necessity. 

The hospital stay was not medically necessary for this patient at the acute inpatient level of care. 

The patient presented to the hospital with abdominal pain and lower extremity pain. However, the abdominal pain was not associated with hemodynamic instability. There were no peritoneal signs on the exam. There was no evidence that the patient had any serious medical problems contributing to the symptoms including aortic dissection, bowel perforation, bowel ischemia, visceral organ torsion, or intestinal obstruction. Although, the ischemia was considered at the time of admission, therefore, an admission to rule out ischemia in the setting of possible previous cocaine use was reasonable.
Admission for an alternate level of care would have been completely reasonable. Overall, the patient remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care.