Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System /Gastrointestinal - Abdominal pain and nausea. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is upheld.

The patient was a male with a past medical history significant for lupus, recently diagnosed terminal ileitis and cecal colitis who presented to the hospital with complaints of abdominal pain that was associated with diarrhea and nausea. The patient reported that his pain was sharp, intermittent, localized in the lower abdomen, and aggravated by lying down. The patient reported loose stools in the last couple of days before his presentation but not on the day of the presentation.
The patient denied headache, weakness, numbness, tingling, lightheadedness, blurry vision, chest pain, palpitations, diaphoresis, shortness of breath, urinary symptoms, and recent travel or sick contacts.
On the physical exam, the patient was afebrile. Heart rate was 73 beats per minute (bpm), respiratory rate 20 breaths/min, blood pressure 123/69, oxygen saturation 99% on room air. The patient was awake, alert, and oriented times 3. He looked comfortable and demonstrated no signs of respiratory distress. The head, eyes, ears, nose, throat (HEENT) exam was within normal limits. The neck was supple without lymphadenopathy, masses, jugular vein distention (JVD), and carotid bruits. The patient had a regular rate and rhythm, without murmurs, rubs, or gallops. Lungs were clear to auscultation without wheezes, rales, or rhonchi. The abdomen was soft with some tenderness but negative Murphy's sign. Bowel sounds were present. The rest of the physical exam was unremarkable. Imaging studies included a chest x-ray, which was clear.
Computed tomography (CT) of the abdomen and pelvis revealed cecal colitis and terminal ileitis. This was most concerning for inflammatory bowel disease, although infectious etiologies were not excluded. There was a small amount of ascites. There was an inflamed appendix, which was felt to be secondary to the inflammatory process rather than primary acute appendicitis.
Laboratory evaluation revealed that sodium was 133, potassium 4.5, creatinine 0.9, blood urea nitrogen (BUN) 19, and glucose 90. Total bilirubin was 1.8, direct bilirubin 0.7. Transaminases were normal. White blood cell count was 6.3, hemoglobin 13.6, hematocrit 41, platelets 356.
The patient was admitted to the hospital with cecal colitis and terminal ileitis concerning inflammatory bowel disease. Gastrointestinal (GI) and infectious disease services were consulted.
The patient was already seen by general surgery who determined that no surgical intervention was needed.
The gastroenterologist stated that the patient was already started on the intravenous antibiotic Zosyn. Stool studies were sent. They recommended the patient be discharged home with oral Levaquin and Flagyl to complete a 5-day course. The gastroenterologist recommended a colonoscopy as an outpatient to evaluate for inflammatory bowel disease (IBD).
Indirect hyperbilirubinemia was attributed to possible Gilbert syndrome.
The abdominal ultrasound was unremarkable.
Since the patient's clinical condition improved, he was discharged from the hospital the next day after the day of admission.
The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld. 
The hospital stay was not medically necessary for this patient at the acute inpatient level of care.

There was no evidence that he had a severe infection that was associated with bloody diarrhea. There were no reports of the patient being immunocompromised. There were no peritoneal signs on exam or evidence of toxic megacolon. The patient remained hemodynamically stable. There were no reports that his vomiting was severe or persistent and caused significant dehydration or severe electrolyte abnormalities. There was no mention that the patient was unable to maintain oral hydration.
Overall, the hospital stay was relatively short, and the patient initially received treatment with intravenous antibiotics with a subsequent transition to oral antibiotics.
Taking into consideration all these facts, the patient could be safely managed at a lower level of care status.