Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient Hospital Stay
The insurer denied the inpatient hospital stay.
The determination is upheld.

This is a female patient who presented to the hospital emergency department (ED) with symptoms of abdominal pain and nausea. Comorbid health conditions included a prior Cesarean (C)-section and hysterectomy, but no chronic medical conditions. Her ED evaluation included labs and a computed tomography (CT) scan that showed a dilated esophagus, stomach, and proximal small bowel with a gradual transition to collapsed bowel. This was thought to be consistent with an element of small bowel obstruction. At the time of presentation, the patient was without a fever and her vital signs were normal. The white blood cell (WBC) count was normal (3.9 thousand [K]). The complete metabolic panel identified normal liver enzymes, normal renal function, and normal electrolytes.

The patient was initially treated with intravenous (IV) fluid and nothing by mouth (NPO) status. Surgical consultation was requested. The patient reported no abdominal pain or vomiting. Her vital signs were normal. The abdominal exam was normal. The diet was advanced to full liquids and was tolerated. The patient remained clinically stable with normal vital signs and no reported abdominal pain. She was discharged from the inpatient setting with plans for short term outpatient follow up.

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

An inpatient level of care was not medically necessary in this case. This is a patient without reported comorbid illness. She presented to the hospital ED with abdominal complaints. Evaluation at the ED suggested the possibility of a bowel obstruction. The patient was hemodynamically stable at the time of presentation. The patient was admitted to the hospital and was provided IV fluid and NPO status. There is no documentation of a hemodynamic, pulmonary, neurological, or metabolic reason for an acute inpatient level of care at the time of presentation. A surgery consultation was requested. The patient was without abdominal pain and was able to be started on a diet. While the patient was initially NPO, she was able to be started on a diet within one day.
 
There is no documentation of the need to care for comorbidities that required inpatient admission or any other condition requiring inpatient admission. Acute inpatient care was not medically necessary for this patient as the care and treatment provided could have been provided with a lower level of care. This lower level of care would have provided for surgical consultation, provision of IV fluid, imaging, lab assessment, and overnight care. A lower level of care would have been consistent with the Milliman Care Guidelines (MCG). Inpatient hospital stay related to bowel obstruction may be needed for complete bowel obstruction or partial obstruction with significant signs or symptoms such as inability to maintain oral hydration, vomiting, significant pain, electrolyte abnormalities, or care for active comorbidities. In this case, none of these conditions existed and the patient had resolution of her abdominal complaints within one day.