Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal pain
Treatment: Inpatient hospital admission
The insurer denied coverage for inpatient hospital admission.
The denial is overturned.

This female patient has a past history of multiple problems including polycystic ovary syndrome (PCOS), asthma, C difficile, mononucleosis, anxiety and other problems. The patient presented to the Emergency Room (ER) with right lower quadrant (RLQ) pain. The patient also had nausea, diarrhea, and some blood in the stool.  The patient had a normal RLQ ultrasound and abdominal computed tomography (CT) scan in the ER.  A surgical consult was obtained and they felt that this was not appendicitis.  Despite these normal tests, this patient's abdominal pain did not improve and she was admitted. The patient's pain continued and she had minimal oral intake so she received intravenous (IV) fluids and pain medication.  Because she could not keep hydrated orally and pain was not controlled, inpatient admission was medically necessary for this patient. The patient had a normal esophagogastroduodenoscopy (EGD) and colonoscopy, and still had abdominal pain in the same evening. The patient's oral intake was still minimal at this time, and continued admission was necessary. A capsule endoscopy was attempted, but the patient vomited.  The patient had severe abdominal pain in the morning, but gradually improved.  The patient's oral intake improved and she was then considered stable for discharge.

Per Gomez-Suarez R. (2016), "Recurrent abdominal pain is a frequent pathology seen in the pediatric gastroenterology practice. In fact, most children with abdominal pain symptoms have functional disorders of the gastrointestinal tract.  A focused medical history, comprehensive physical examination, and minimal testing are often enough to establish the diagnosis.  The presence of red flags such as rectal bleeding, bilious vomiting, fever, and arthralgia should alert providers as well as direct further diagnostic and therapeutic plans." And as per Smith J, Fox SM. (2016), "Abdominal pain is a common complaint that leads to pediatric patients seeking emergency care.  The emergency care provider has the arduous task of determining which child likely has a benign cause and not missing the devastating condition that needs emergent attention."

Based on the review of the medical record and literature, the acute inpatient stay was medically necessary for this patient.  Abdominal pain is very common in pediatric patients. The differential diagnosis is very broad and can include very serious problems that should not be missed.  When the underlying disease is not serious, often there is quick improvement once the patient is admitted and given intravenous (IV) fluids and minimal oral intake. However, in this case, the patient continued to have severe abdominal pain each day, and inability to tolerate oral intake. Even if there was no underlying pathology identified and the emotional/anxiety component may have been prominent for this patient's case, the patient could not be have been safely discharged until the patient's pain was better controlled.  The patient's oral intake was not adequate on any day except towards the end of the inpatient stay.  Therefore, inpatient admission was medically necessary for this patient. 

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for acute inpatient should be reversed.  The medical necessity is substantiated.