Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastroenteritis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

 
This is an adolescent with no significant past medical history who presented to Maimonides Medical Center emergency department (ED) with 2 week history of abdominal pain and one day of severe chest pain. On further evaluation, there were findings of coagulopathy, splenomegaly, and bilateral pleural effusion. The patient was admitted for further work up. 

Presenting vital signs were Temperature 99.6 degrees F, Heart Rate 93, Blood Pressure 141/93, oxygen saturation on room air 98%. Abdomen was soft, mildly distended, diffusely tender with significant tenderness over epigastric and right upper quadrant (RUQ), positive Murphy's sign. No guarding or rebound.  No palpable organomegaly. Recommended to admit for further work up of abdominal pain and chest pain, pain control and Rheumatology, Hematology/Oncology consult. Given Morphine 4 milligrams (mg) once for pain relief.

Electrocardiogram (EKG) sinus tachycardia, Chest X-Ray was nonrevealing and bedside echocardiogram without effusion, normal cardiac activity. Right Lower Quadrant (RLQ) Abdominal ultrasound was unable to identify appendix, Pelvic ultrasound showed trace fluid in RLQ, Abdominal/Pelvis computed tomography (CT) showed splenomegaly up to 15 centimeters (cm), trace bilateral pleural effusion, trace fluid in Morrison's pouch and pouch of Douglas, otherwise no visible acute pathology.

Laboratory results showed slightly elevated neutrophils, otherwise within normal limits. Alanine transaminase (ALT) 51, aspartate transferase (AST) 22, bilirubin within normal limits (WNL), C-reactive protein (CRP) WNL, lipase WNL, activated partial thromboplastin clotting time (aPTT) &gt;100, respiratory viral panel (RVP) Negative, d-dimer WNL, lupus screen positive, erythrocyte sedimentation rate (ESR) 32 - elevated.

Progress notes states that patient required Morphine 2mg once for severe (7-10/10) abdominal and chest pain. Later took Motrin for pain 4-9/10. Tolerating crackers. Attending physician recommended oral analgesics.

Rheumatology consult, unlikely systemic lupus erythematosus (SLE). Cardiology, no additional labs needed, offered to see patient later as an inpatient or 6 months as an outpatient. The patient was managed with oral Motrin/Tylenol with improved pain control. Discharged for follow up with cardiology in 6 months, Rheumatology and Hematology/Oncology in one month, pediatrician in one week.

1-2% of children with acute abdominal pain will have a serious disease process whereas the remainder have self-limited disorders.(1)  

According to 2014 guidelines for the management of acute gastroenteritis in children, indications of hospitalization for acute gastroenteritis in this population include shock, severe dehydration, neurological abnormalities (lethargy, seizures, etc.), intractable or bilious vomiting, failure of oral rehydration, and/or suspected surgical condition.(2) 

Based on the above, the patient did meet the guidelines for admission. Outside of 2 doses of Morphine (one in ED and second during first night on the inpatient floor), her pain was managed with oral analgesics. She remained stable throughout the admission with intermittent tachycardia/hypertension (both improved with pain control).

In terms of coagulopathy, the patient did not have any signs of active bleed. Although there was a concern for an autoimmune process (i.e., Lupus), the rheumatologist felt the patient did not fit exact criteria at the time of evaluation clearing patient for discharge with one month follow up as outpatient.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for inpatient hospital admission is not substantiated.