Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal - Abdominal Pain.
Treatment: Inpatient Hospital.
The insurer denied Inpatient Hospital Services.
The denial is upheld.

The patient is a female with a past medical history significant for hypertension, aortitis of the descending aorta requiring recent hospitalization, prior liposuction, and breast reduction surgery, who came to the emergency department with complaints of abdominal pain for one week. The patient described sharp pain in the abdomen with radiation to the back at times. She also complained of some mild chest discomfort. The patient stated that she had similar symptoms while admitted at the prior hospital just a few days before her current presentation. It was also noticed that the patient had a visible abdominal hernia, and the pain was localized there. 
It was mentioned in the history and physical (H&P) note that the patient was initially evaluated at another hospital by a vascular surgery team, and they recommended consultation with thoracic surgery due to concerns for newly diagnosed distal thoracic outpouching. The thoracic surgery team stated that they did not operate in the distal aorta unless concerns for tracheal involvement existed and they recommended consulting with another vascular surgery team. The patient was transferred for vascular evaluation. The vascular surgery team stated that it was difficult to differentiate aortitis from intramural hematoma and believed that this was more consistent with a known history of aortitis, and the patient would benefit from medicine admission for corticosteroids and blood pressure control.
A computed tomography (CT) scan of the abdomen and pelvis with intravenous contrast demonstrated intramural hematoma in the visualized portion of the descending aorta extending into the infrarenal abdominal aorta to the aortic bifurcation. The proximal portion was not included in the field of view. In the distal descending thoracic aorta, there was right-sided outpouching compatible with an ulcer-like projection, and a more distal posterior focus of contrast compatible with the intramural blood pool. The celiac artery, superior mesenteric artery, and bilateral renal arteries were opacified. A 2.5-centimeter hypertensive structure abutting the right uterine fundus, which could represent a finding of an exophytic fundal fibroid, was seen.
The patient was admitted to the hospital with aortitis and intramural hematoma. In the hospital, the patient was evaluated by a vascular surgery team. No vascular intervention was required.
The vascular surgery team recommended treatment with oral corticosteroid taper as was recommended in the discharge instructions from prior hospital. 
At issue is the medical necessity of the Inpatient Hospital Services.

The health plan's determination of medical necessity is upheld in whole.

The requested health service/treatment of Inpatient Hospital Services was not medically necessary for this patient.
In this clinical case, the patient presented to the hospital with abdominal pain that was attributed to previously diagnosed aortitis and luminal hematoma. By the time of the current admission, those diagnoses were already established. The imaging studies including a CT angiogram of the aorta were not much different from the imaging studies performed during the previous hospitalizations where the definitive diagnosis was established. The review of the medical records clearly demonstrated that the abdominal pain was not associated with hemodynamic instability or peritoneal signs. The imaging studies clearly demonstrated the patient did not have aortic dissection and did not need any surgical intervention.  There was no mention that the evaluation of the abdominal pain required the patient not to eat or drink for an extended period of time. 
Therefore, the requested health service/treatment of Inpatient Hospital Services was not medically necessary.