Appeal type: Medical necessity
Decision: Overturned

Digestive System/Gastrointestinal -Other
Inpatient Hospital

The patient is a female who presented to the emergency department (ED) with acute onset abdominal pain, nausea, vomiting of several hours' duration. Her past medical history was significant for hysterectomy and ventral hernia with lysis of adhesions. Her heart rate at the time of presentation was 89/minute. The abdomen was mildly tender without distension. Her white blood cell (WBC) count was normal at 7.2 thousand (K). Potassium and renal function were normal per the basic metabolic panel. The patient was evaluated with computed tomography (CT) scan of the abdomen and pelvis that showed dilated small bowel consistent with bowel obstruction.
The patient was admitted to the hospital and treated with intravenous (IV) fluid, antiemetics, and pain medication. The admitting diagnosis was bowel obstruction.
The following day the patient was evaluated with a small bowel follow through that showed normal passage of contrast through the small bowel. The progress note describes mild abdominal distension. The WBC count was down to 5.3 K.
On the day of discharge, physical examination was improved with less tenderness. The diet was advanced, and she was considered to be stable for discharge from the hospital.
The health plan rationale for denial is that there is no documentation of unstable vital signs or notes that there was a blockage of the bowel, dehydration, ongoing vomiting, need for ongoing fluid, or need for emergency surgery. The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is overturned.

The submitted records support that this patient presented with acute onset of abdominal pain. She was approximately 5 weeks status post-surgery for a bowel obstruction. She had pathology identified on CT scan that indicated possible bowel obstruction. She was monitored with daily examination and surgical consultation. Her condition did gradually improve over 48 hours. On the day of discharge she reported less pain and there was improvement based on fluoroscopic imaging.
An inpatient designation was appropriate as the presenting condition, the CT imaging, the anticipated length of stay, and the intensity of service were consistent with an inpatient level of care. Inpatient admission was appropriate in this case as there was a high index of suspicion that her care would extend for at least 48-hours. Her evaluation required that she not eat or drink initially. Her severity of pain and the pathology identified on CT scan were such that her clinical condition was judged too severe to be within scope of care at a lower level status. This included severe pain requiring acute inpatient management, identification of etiology of the suspected obstruction, and failure to pass flatus, and signs of intestinal obstruction.

MCG-abdominal pain, undiagnosed 22nd edition state that admission is indicated for 1 or more of the following: Surgery is needed that cannot be performed on ambulatory basis, peritoneal signs present, evaluation requires patient to not eat or drink for an extended period (more than 24 hours), significant finding or clinical condition judged too severe or too persistent to be within scope of observational care including one or more of the following: hemodynamic instability, severe pain requiring acute inpatient management, identification of etiology or finding that requires inpatient care, absent bowel sounds with complete ileus, signs of intestinal obstruction, suspected toxic megacolon, severe electrolyte abnormality, high fever or infection, other significant finding or clinical condition judged not to be within scope of care at a lower level status. In this case the patient's condition was thought to be related to an intestinal obstruction. Additionally, the findings of the CT scan were thought to represent an acute surgical emergency. 
She was appropriately evaluated for her presenting condition with surgical consultation. She was appropriately monitored with imaging, lab data, and follow up clinical assessment during her inpatient confinement. An inpatient level of care was consistent with standards of care.