Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Mesenteric Adenitis
Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.
The denial is upheld.

The patient has a benign past medical history who presented to the Emergency Department complaining of intermittent mid abdominal pain x several weeks and constipation x (for) 4 days. He was noted to be febrile and tachycardic. Chest and abdominal x-rays were unremarkable. He was transferred to another hospital emergency department to rule out appendicitis. 

There was no associated nausea, vomiting, distension or bleeding. The patient's vitals on arrival were notable for Temperature 100, Heart Rate 140, Respiratory Rate 22, Blood Pressure 110/59 and room air oxygen saturation of 99% (percent). Admitting weight was 53 kilograms. Physical exam showed an awake and alert male in no apparent distress. He had moist mucus membranes with normal capillary refill and normal skin turgor. Lungs were clear with normal effort. Cardiac exam was unremarkable. Abdomen exam was soft with mild diffuse tenderness to palpation. There was no associated organomegaly, distension, guarding, rebound, or masses. There was no rectal exam reported. Admitting laboratories were notable for white blood cell 18.6 (neutrophils 87.4%, no bands), hemoglobin 11.2, platelet 275, amylase 40, lipase 5, c-reactive protein (CRP) 12.14 and a normal liver profile for age. Urinalysis was notable for specific gravity 1.020/pH (potential of hydrogen) 6 and dip + (plus) ketones and trace protein. Nasal viral washings were negative. Imaging included a bedside abdominal sonogram that showed a normal biliary tree, normal appendix, scattered mesenteric lymph nodes, jejunal inflammation and possible inflammation around the pancreatic head with a normal appearing pancreas body and tail. He received a 1000cc (cubic centimeter) bolus of normal saline. He developed a fever (T (temperature) 101.4 F (Fahrenheit)). 

This child appears to have mesenteric enteritis (without diarrhea) and constipation with associated bowel spasms. He was not dehydrated by the time of admission to his floor bed, had no vomiting and no abdominal distention.  In accordance with a review of the approach to the 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. His imaging excluded any serious conditions to merit the inpatient setting. Once admitted his pain and fevers were controlled on oral medications.
 
This child's imaging suggested mesenteric adenitis. His tachycardia had resolved (except during fever) after his second normal saline bolus that occurred more than 9 hours after his transfer to the other hospital. His lack of vomiting, favorable physical exam, unremarkable imaging, and lack of localizing symptoms excluded many of the serious conditions meriting admission. He was able to hydrate himself. The intravenous antibiotics chosen to treat his leukocytosis and CRP both have high bioavailability achieving nearly the same levels in the blood as the oral formulations. He was able to hydrate himself and his intermittent pain and fever responded to oral Tylenol/Advil. He received antibiotics for only 1 day.

Given these facts the acute admission was not medically necessary or in the best interest of the patient. 

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the inpatient hospital admission is upheld. Medical Necessity is not substantiated.