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.

The patient is a male with a medical history of obstructive sleep apnea and hyperlipidemia. He presented to the emergency department with severe lower and right-sided abdominal pain with fever, chills, and nausea. His vital signs were notable for an elevated blood pressure of 146/78 millimeters of mercury (mmHg). His physical examination was notable for soft and with guarding and tenderness in the lower abdomen (right more than left). The laboratory studies (labs) showed an elevated hemoglobin of 16, a hematocrit of 47 percent (%), an elevated aspartate aminotransferase of 38, and an elevated alanine aminotransferase of 54.
The chest x-ray showed no gross pulmonary infiltration or effusion, and mild bibasilar markings. The ultrasound of the abdomen showed hepatic steatosis, unremarkable gallbladder, and right lower renal angiomyolipoma measuring 7 millimeters (mm). The computed tomography (CT) scan of the abdomen and pelvis showed no acute visceral pathology, consider hepatic steatosis, left nephrolithiasis, and diverticulosis. He was treated with intravenous fluids, Ketorolac, Morphine, Hydromorphone, Ciprofloxacin, and Metronidazole. He was made nothing by mouth. He was noted to have no acute events overnight, and persistent pain. The labs showed an unremarkable complete blood count, elevated aspartate aminotransferase of 38, and elevated alanine aminotransferase of 50.
The gastroenterology consultation noted abdominal pain secondary to uncertain etiology; the recommendation was to continue intravenous fluids, serial abdominal examinations, advance diet as tolerated, consider colonoscopy as outpatient, consider repeat CT (computed tomography) scan if pain persists or worsens, and correct electrolyte abnormalities. He had improvement in symptoms. 
 
In this case, the patient presented with abdominal pain, nausea, fever, and chills. This was consistent with inflammation (esophagitis, gastritis, duodenitis, peptic ulcer disease) or gastroenteritis; however, there was no sustained tachycardia or hypotension, gastrointestinal bleeding, acute pancreatitis, gastrointestinal perforation, abscess, fistula, peritonitis, sepsis, or bowel obstruction; appropriate therapy was provided with intravenous fluids and empiric antibiotics [1-5]. An endoscopy during the hospital stay was not deemed necessary. The patient had improved and was discharged with outpatient follow-up. All of the measures that were undertaken, such as observation, monitoring, labs, gastroenterology consultation, and empiric antibiotic therapy, could have been performed without the acute inpatient level of care, at an alternate level of care [2-5].
Per the Milliman Care Guidelines for Abdominal Pain, Undiagnosed, the inpatient level of care is not supported. Per the Milliman Care Guidelines for Abdominal Pain, Undiagnosed criteria:
Admission is indicated for 1 or more of the following:
-Hemodynamic instability (NOT MET)
-Severe pain requiring acute inpatient management (NOT MET - interventions performed for pain could have been performed at the observation level of care)
-Peritoneal signs (NOT MET)
-Identification of etiology or finding that requires inpatient care (e.g., aortic dissection, bowel perforation, bowel ischemia, visceral organ torsion, intestinal obstruction) (NOT MET)
Evaluation requires patient to not eat or drink for extended period (e.g., more than 24 hours) (NOT MET)
-Inability to maintain oral hydration (e.g., needs intravenous (IV) fluid support) that persists after observation care (NOT MET)
-Suspected toxic megacolon (NOT MET)
-Bacteremia (NOT MET)
-Procedure needed that cannot be performed on an ambulatory basis (NOT MET).

The health plan's determination of medical necessity is upheld in whole.