Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Digestive System/Gastrointestinal.
Treatment:  Inpatient Hospital Stay.

The insurer denied the Inpatient Hospital Stay.  The determination is upheld.

The patient presented to an outside emergency room (ER) with a complaint of 1 month of nausea, vomiting, decreased appetite and a 9 pound (lb.) weight loss.  His mother reported that he began experiencing nausea and vomiting after meals 1 month prior, approximately 0-1 episodes of vomiting a day with diffuse abdominal pain.  Over the course of the month, the patient began eating less and less due to a fear of belly pain and vomiting.  His mother also reported that the patient typically stools every day but that the stools are hard balls.  His last bowel movement (BM) was 1 day prior to arrival.  They initially presented to the primary medical doctor (PMD), who performed some lab testing and an abdominal x-ray, which were normal.  The mother brought him to the ER as she felt he was not improving.

In the ER he had a complete blood count (CBC), comprehensive metabolic panel (CMP), and chest x-ray (CXR) done,  which were normal.  He had an electrocardiogram (EKG) notable for sinus bradycardia and the cardiology fellow recommended thyroid studies.  His thyroid stimulating hormone (TSH) was found to be elevated with a normal T4.  He was transferred to the accepting facility for bradycardia.

Upon arrival to the floor, the patient was very fussy and agitated.  He was admitted with diagnoses of abdominal pain, vomiting and weight loss.  Reportedly, his HR had stabilized by the time he was admitted.  The admission assessment stated the patient was currently stable and very well-appearing with a benign abdominal exam.  Although his mother reported significant weight loss, it seemed to be in part due to patient's fear of symptoms returning.  The patient's weight was plotted in the 75-90th percentile for weight.  The primary medical doctor (PMD) gave a report that approximately 4-5 weeks prior the child had an abdominal ultrasound (US), CBC and CMP that were normal, and the child was referred to gastroenterology (GI).  The TSH was 5.94, upper limit of normal for age about (~) 5.4.  The case was discussed with endocrinology, and they did not believe this was the underlying etiology of his presentation.  Upon admission, an abdominal x-ray was ordered which showed mild stool burden but was otherwise unremarkable.  The patient was started on Miralax twice daily (BID) with good response.  The mother reported softer stools after this.  Throughout the admission, he remained afebrile and was monitored on telemetry.  He was not bradycardic, maintained a HR of the 80s-90s.  Endocrinology was consulted regarding concern for hypothyroidism.  They determined that his TSH was not elevated for his age, and the remainder of his thyroid studies were normal; no intervention was required.  The patient's weight was discussed with the PMD and he apparently lost 10-11 lbs. over 10 months.  He was referred to GI but his mother had not secured an appointment as yet.  The GI team recommended some screening labs and follow up as an outpatient.  The patient was monitored overnight to ensure that he was able to eat and drink, which he tolerated well, without any further episodes of emesis, and he was no longer complaining of abdominal pain.  The patient was deemed stable for discharge home with outpatient GI follow up.  He was advised to follow up with his pediatrician within 1-2 days of discharge.  At issue is the medical necessity of an inpatient stay.

The requested health/service of inpatient stay was not medically necessary for this patient.  This patient presented with a 1-month history of symptoms that included abdominal pain, intermittent vomiting, weight loss and constipation.  None of the conditions mentioned in his assessment had associated features that warranted inpatient level of care.  He was noted to have bradycardia that resolved spontaneously and was not persistent.  If there was concern for a return of the bradycardia, he could have been monitored in the ER for a few hours to ensure it did not return.  Furthermore, the patient was stable with a normal blood pressure during the episode, which spoke to the benign nature of this finding.  This was voiced by the cardiologist, as well.  He had an elevated TSH associated with a normal T4 that when evaluated by the endocrinologist was deemed to be normal for his age.  This could have been determined in the ER, and he did not need to be admitted to inpatient level of care for the endocrinologist to make this determination.  As far as his constipation, the patient had an abdominal x-ray upon admission that revealed mild stool burden.  His complaints of poor by mouth (PO) intake and abdominal pain had been intermittent for approximately 1 month.  He was already referred to a GI as an outpatient.  He did not have any acute change in his symptoms or any significant laboratory aberrations or metabolic derangement from these symptoms.  Given the findings at admission and the low level of care provided during his short admission, an inpatient stay was not medically necessary for this patient.