Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain

Treatment: Inpatient stay

The insurer is denied coverage for inpatient stay.
The denial is upheld. 

The patient was then a female with a past medical history of anemia, migraines, and gastric bypass surgery. The patient had a recent trip overseas. The patient presented to the Emergency Department (ED) with subjective complaints of diarrhea for days. The patient also complained of abdominal pain. The patient stated that she had this similar presentation in the past and was told that she had colitis at the time with blood in her stool. The patient reported that the diarrhea only happened right after she ate. The patient had a blood pressure of 99/60. On exam, the patient had tenderness to palpation in the left upper and lower quadrant of the abdomen. The patient's white blood cell (WBC) count was 10.5 with 11% bands. The patient's hemoglobin was 9.4 with MCV of 60. The patient's urinalysis was negative. The patient's computed tomography (CT) scan of the abdomen and pelvis were negative, showing postsurgical changes. The patient's symptoms were thought to be possibly due to infectious gastroenteritis in the setting of recent travel and elevated white blood cell count with bands. It was also thought that the patient might have irritable bowel disease in the setting of previous colitis in the spring with bloody stool as well as her young age. Additional diagnosis considered was possibly dumping syndrome in the setting of gastric bypass surgery and nonadherence to diet; but this was less likely since the surgery was prior to this presentation. There was also the possibility of peptic ulcer disease (PUD) in the setting of anemia due to this patient's use of Excedrin for migraines. The patient underwent a CT scan of the head which revealed a possible borderline Chiari malformation.

 The patient was admitted to Medicine with a diagnosis of abdominal pain. The treatment plan included a follow-up anemia profile, orthostatic vital signs, stool guaiac, stool culture, stool ova, and parasite testing, stool white blood cells, stool calprotectin, stool electrolytes, Helicobacter pylori testing, and a gastrointestinal consultation. The patient was kept on a clear liquid diet. The gastrointestinal (GI) services noted a concern for an infectious cause of symptoms or a foodborne illness, and requested additional lab testing (ESR and CRP); a bland diet was recommended. The patient's laboratory studies were consistent with iron deficiency anemia. The patient's colonoscopy with biopsies was performed to rule out Crohn's disease. The patient was discharged.

According to literature review, patients that need hospitalization are those with the following signs and symptoms: significant volume depletion/dehydration, altered mental status, significant rectal bleeding, severe unrelenting abdominal pain, comorbidities such as immunocompromised disease and diabetes (immunocompromised status), age >=65 years, recent hospitalization or antibiotics, pregnancy, or weight loss. In this case, there was no fever or severe abdominal pain requiring hospital admission rather than ambulatory setting such as observation. The patient's lab data showed no electrolyte discrepancy, acid/base derangement, or renal impairment that needed acute hospital inpatient admission status. Intravenous hydration, IV pain medications, and monitoring in the ambulatory setting would have been appropriate for this patient and would not have jeopardized her well-being. Thus, inpatient admission was not medically necessary for this patient.

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

The carrier's denial of coverage for the acute inpatient stay should be upheld. The medical necessity is not substantiated.