Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male with a past medical history of hypertension and hyperlipidemia who presented to the hospital with complaints of dizziness and melena for one day. On the day of admission, he noticed a black tarry stool that was associated with lower abdominal pain, which subsequently resolved. The patient took Tylenol and then presented to his primary care physician's (or provider) (PCP) office, who directed him to come to the emergency department. The patient denied any previous history of gastrointestinal bleeding and never had an esophagogastroduodenoscopy (EGD) or a colonoscopy before. He reported taking Aspirin but no other non-steroidal anti-inflammatory drugs (NSAIDs). The patient reported drinking alcohol socially. He endorsed nausea but denied vomiting and loss of consciousness.

On the physical exam, he was afebrile. His heart rate was 96 beats per minute (bpm), blood pressure was 119/77, respiratory rate 22 breaths/minute and oxygen saturation 95 percent (%) on room air.

The patient was in no acute distress. The head, eyes, ears, neck, throat (HEENT) exam was within normal limits. The patient had a regular rate and rhythm, without murmurs, rubs or gallops. His lungs were clear to auscultation without wheezes, rales or rhonchi. His abdomen was soft, non-tender to palpation, with normal bowel sounds without guarding or rebound. There was no edema in the extremities. The patient was awake, alert and oriented times 3.

The laboratory evaluation revealed that his sodium was 138, potassium 3.5, chloride 106, bicarbonate (HCO3) 26 and creatinine was 0.81. His white blood cell count was 8.9, hemoglobin 13.2 and platelets were 414. On the repeat complete blood count (CBC) his hemoglobin went down to 11.3 and his liver function tests were normal.

An electrocardiogram (EKG) revealed sinus tachycardia with an incomplete right bundle branch block. A computed tomography (CT) angiogram of the abdomen revealed no evidence of active gastrointestinal bleeding. There was no mention of any acute findings in the abdomen or pelvis. The patient had a distended urinary bladder. A chest x-ray showed no evidence of an acute cardiopulmonary process.
The patient was admitted to the hospital with abdominal pain and possible gastrointestinal bleeding and received treatment with intravenous Protonix.
The patient was evaluated by a gastroenterologist who performed the EGD which revealed a tortuous esophagus and erythematous mucosa in the antrum. There was a non-bleeding duodenal ulcer with a clean ulcer base. The 2nd portion of the duodenum was normal.
The gastroenterologist recommended continued treatment with proton pump inhibitors and follow-up with the gastrointestinal (GI) clinic as an outpatient.
During the hospital stay, the patient remained in stable clinical condition.
The reason for dizziness was unclear since the patient was hemodynamically stable and his initial hemoglobin was completely normal. The patient did not need a transfusion of packed red blood cells.

The patient had no evidence of coagulopathy or a critically low platelet count. During the hospital stay, the patient remained in stable clinical condition and did not need any diagnostic procedures or interventions necessitating admission at the acute inpatient level of care.
There was no evidence that the patient had clinical signs of hemodynamic instability, or severe pain requiring acute inpatient management. This patient did not need urgent surgery.