Appeal type: Medical necessity
Decision: Upheld

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


The patient is a male with a past medical history significant for polysubstance abuse including heroin and cocaine who presented to the emergency department with complaints of abdominal pain and vomiting. The pain was located in the left groin area where the patient had an inguinal hernia. He also complained of bilious vomiting. The patient denied a fever, chills, chest pain, palpitations, dysuria, or diarrhea.
While in the emergency department, the patient underwent a computed tomography (CT) scan of the abdomen and pelvis that demonstrated no evidence of a bowel obstruction, colitis, diverticulitis, or appendicitis. The urinary bladder was decompressed but showed mild wall thickening and urothelial enhancement. There was an indeterminate, approximately 2.4 cm ill-defined hypodense lesion within the inferior right hepatic lobe. Further evaluation with magnetic resonance imaging (MRI) was recommended.
When the patient was seen by the admitting physician, he was afebrile. His pulse rate was in the range between 92 and 115 beats per minute (bpm), and the respiratory rate was normal. The systolic blood pressure was in the range between 188 and 214, and the diastolic blood pressure was 106-136. The oxygen saturation was normal.
The patient was awake and in no acute distress. His speech was clear. The patient followed commands. His lungs were clear to auscultation bilaterally. He had a regular heart rate and rhythm. The abdomen was soft, non-tender, and non-distended. Bowel sounds were present. There was a left inguinal hernia that was not observed when the patient stood up. No lower extremity edema was mentioned.
Laboratory evaluation revealed that the white blood cell count was 10.3, hemoglobin 16.8, hematocrit 48.1, and platelets 353. The sodium was 133, potassium 4.0, chloride 100, bicarbonate 18, blood urea nitrogen (BUN) 15, creatinine 1.52, glucose 253. Two hours later the patient had another basic metabolic profile that demonstrated that the sodium was 136, potassium 4.3, chloride 100, bicarbonate 24, BUN 16, creatinine 1.27, and glucose 170. A urinalysis showed rare bacteria. Otherwise, it was negative.
The patient was admitted to the hospital. He initially received treatment with intravenous fluids, but subsequently was transitioned to a clear liquid diet. Antiemetics were initiated. It was noted that the patient had an elevated blood pressure that was consistent with hypertensive urgency.
In the hospital, the patient was seen by general surgery for evaluation of a left inguinal hernia. No surgical intervention was recommended. The patient was advised to have an ambulatory follow-up with general surgery for outpatient repair of the left inguinal hernia.
During the hospital stay, the patient was diagnosed with gastroenteritis, but his symptoms improved relatively rapidly. The patient was started on methadone due to his history of polysubstance abuse to avoid withdrawal symptoms.
Magnetic resonance imaging (MRI) of the abdomen was performed for evaluation of liver lesion. The lesion was most consistent with a hemangioma. During the hospital stay, his clinical condition improved and the patient was cleared for discharge.
At issue is the medical necessity of an inpatient stay.

The hospital stay was not medically necessary for this patient at the acute inpatient level of care.
The patient had abdominal pain which was not associated with hemodynamic instability or peritoneal signs. There was no evidence that it was severe enough to justify admission at the acute inpatient level of care. There was no evidence that the abdominal pain was the result of serious medical conditions such as aortic dissection, bowel perforation, bowel ischemia, visceral organ torsion, or intestinal obstruction. There was no mention that the abdominal pain was associated with bacteremia or toxic megacolon.
The evaluation of the abdominal pain did not require the patient not to eat or drink for an extended period of time. The patient most likely had acute gastroenteritis, which is a self-limiting condition not requiring admission at the acute inpatient level of care. It was clearly indicated that the patient had hypertensive urgency, a condition that generally does not require admission at the acute inpatient level of care.
There was no compelling clinical reason why the patient could not have safely and appropriately received evaluation and treatment at a lower level of care with subsequent transition to outpatient care, rather than admission to an inpatient level of care.
Overall, he remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care.