Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Intestinal obstruction, vomiting, nausea, abdominal pain, and diarrhea 
Treatment: Inpatient Hospital Stay 
The insurer denied the inpatient hospital stay. 
The denial is upheld. 

The patient is a female who presented for purulent discharge from her incision and had undergone an open abdominal myomectomy. She reported malaise, nausea with emesis, abdominal distention for 1 day and not passing flatus with watery bowel movements. The patient denied any fever. The patient had no chills but reported malaise and fatigue. She had no dyspnea or chest pain. She reported vomiting, nausea, abdominal pain, and diarrhea. There was no musculoskeletal pain noted. The patient was noted to be in no acute distress and resting comfortably. Her lungs were clear to auscultation and the heart was regular rate and rhythm without murmurs, rubs, or gallops. The abdomen was soft, nondistended and nontender. Bowel sounds were decreased. There was a 1.5 centimeter (cm) wound separation on the left corner with a small amount of dark bloody discharge. The wound was probed with a sterile Q-tip which did not go through. There was no purulent discharge. There was no surrounding erythema or edema. There was no edema or calf tenderness.

The patient was seen and examined and was noted to be afebrile and doing better. She reported passing flatus but still had some diarrhea. She was continued on a clear liquid diet and encouraged ambulation with the use of incentive spirometer. The patient had a normal examination with her bowel sounds being soft. The patient remained afebrile and was doing well with ambulation. She was passing gas and tolerating a diet. She was planned for discharge and to be follow up in the office.

There was no need for acute surgical intervention.

Review of the acute abdominal series x-ray noted that there was a possible small bowel obstruction. A repeat study noted findings consistent with partial small bowel obstruction versus ileus. Her x-ray exam noted a left abdominal small bowel distention likely partial obstruction with residual contrast remaining within the left and proximal transverse colon.

At issue is the medical necessity of the inpatient hospital stay.

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

The requested health service/treatment of inpatient hospital stay was not medically necessary for this patient.

There was no medical necessity for admission to an acute inpatient level of care for intestinal obstruction. In this case, the patient presented with nausea, vomiting, and diarrhea but did not have a complete or total obstruction. She was able to be managed with intravenous (IV) fluids and nothing by mouth (NPO) status and there was no indication for surgical intervention. There were normal labs of a complete blood count, metabolic panel, and liver functions. She was noted to resolve with bowel rest. The patient had no feculent vomiting and normal vital signs without hypotension. Electrolytes were normal by metabolic panel. There were no acute surgical signs to support bowel ischemia or suspected perforation. A surgical consultation was noted to agree with the findings. The imaging study did not support an ongoing bowel obstruction requiring ongoing nasogastric (NG) tube placement. Surgery did not feel this was needed.
Therefore, the requested health service/treatment of inpatient hospital stay was not medically necessary.