Appeal type: Medical necessity
Decision: Upheld

Diagnosis: lower abdominal pain

Treatment: inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

This is a young adolescent with a past medical history notable for intermittent asthma, constipation, attention deficit disorder, anxiety, Clostridium difficile (C. diff) colitis and ulcerative colitis. The patient presented to the Emergency Department (ED) complaining of fleeting recurrent lower abdominal pain, lasting 2-3 minutes on and off for 5 days, nausea without vomiting and 2 formed stools with blood earlier in the day. She was tolerating liquids but had decreased intake/appetite. There was no associated fever, vomiting, diarrhea, weight loss or dysuria. To treat her ulcerative colitis, she had received 3 doses of Remicade in the previous month and hydrocortisone enemas daily with a plan for scheduled outpatient repeat upper and lower endoscopy. The patient's vitals on arrival were notable for Heart Rate 133 beats per minute, Temperature 37 degrees Celsius, Respirations 24 breaths per minute and room air oxygen saturation of 97%. Admitting weight was 29.9 kilograms. 

Physical exam showed an awake and alert female in no apparent distress. 

Admitting laboratories were notable for sodium 135, potassium 4.3, bicarbonate 21, blood urea nitrogen (BUN) 12, creatinine 0.67, glucose 69 (point of care glucose 94), white blood cell (WBC) 7.9 with a left shift (neutrophils 68%, no bands), hemoglobin 10.6, s 284, C- reactive protein (CRP) 2.6, erythrocyte sedimentation rate (ESR) 43, and a normal liver profile. No urinalysis was submitted for review. Nasal viral washings were negative. Imaging included an abdominal X-ray and an abdominal sonogram both unremarkable. 

She remained afebrile throughout the admission and had no vomiting. Her pain was controlled with additional doses of IV Tylenol (all other medications were given orally and tolerated well), oral gabapentin, oral antispasmodic agents, and oral Imodium. One episode of severe 8/10 pain responded well to her enema. No additional labs or imaging were performed during the admission. Her pain resolved by day 4 and she remained admitted awaiting her elective endoscopy studies. The patient refused the endoscopy prep, and a nasal gastric tube was placed. She underwent an upper and lower endoscopy and was discharged home the same day for outpatient follow-up pending results. Stool calprotectin was 76. GastrointestinaI PCR and C diff were negative. The pathology from the upper endoscopy was negative and from the colonoscopy showed pancolitis L > R.
 
This child appears to have abdominal cramps secondary to residual pancolitis. The blood in her stool was likely from distal colitis +/- a possible fissure. She did not appear dehydrated and had no red flags to suggest a serious condition.  In accordance with a review of the approach to emergency evaluation of acute abdominal pain in children from UpToDate the reasons to admit such an individual would include signs of significant dehydration poorly responsive to intravenous hydration in the Emergency Department, hemodynamic instability, significant electrolyte imbalance, demonstrated oral hydration intolerance to oral challenge, poorly controlled pain with an oral pain medication regimen, concerning physical exam findings for a surgical process or findings consistent with significant blood loss or bowel obstruction. She did not meet any of these criteria. 
 
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 a full hospital admission is not substantiated.