Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Digestive System/Gastrointestinal. 
Treatment:  Inpatient hospital. 

The insurer denied inpatient admission.  The health plan's determination is upheld in whole.

The patient is a female with a past medical history significant for genital herpes, who presented to the hospital with complaints of abdominal pain that the patient described as diffuse.  The pain started several days before the presentation and became worse over the course of several days.  The patient stated that the pain was constant and severe.  The pain was aggravated by urination and bowel movements.  At the same time, the patient denied nausea, vomiting, shortness of breath, dizziness. Reportedly, the patient had a fever up to 101 Fahrenheit (F).

When she was seen by the admitting physician, the temperature was 100.6F, pulse rate 98 beats per minute (bpm), respiratory rate 18, blood pressure was 121/71, and oxygen saturation was 97% on room air.

She was in no apparent distress.  The head, eyes, ears, nose, throat (HEENT) exam was within normal limits.  The neck was supple without lymphadenopathy, masses, jugular vein distention (JVD), carotid bruits.

The patient had a regular heart rate and rhythm, without murmurs, rubs, or gallops. Lungs were clear to auscultation without wheezes, rales, or rhonchi.  There was tenderness in all quadrants, but the abdomen was soft and there was no rebound.  The rest of the physical exam was unremarkable.

The patient was empirically started on intravenous antibiotics that included Zosyn.  Surgical consultation was requested.  According to the surgeon, the patient possibly had gastritis versus pelvic inflammatory disease (PID).

Subsequently, the patient was seen by a gastroenterologist who stated that the patient's symptoms, such as abdominal pain and diarrhea, were most suggestive of acute gastroenteritis.  As a result of the treatment, the patient's clinical condition improved.  She was discharged home on oral antibiotics per infectious disease service recommendations.

The health plan's determination is upheld in whole.

The inpatient hospital admission was not medically necessary for this patient.  

The patient presented to the hospital with complaints of abdominal pain, fever, some diarrhea.  At the same time, the patient remained hemodynamically stable.  The fever and leukocytosis, which were present at the time of admission, significantly improved in the first couple days of the hospitalization.  The patient's clinical condition started to improve after the administration of intravenous fluids, antibiotics.  There was no evidence of significant dehydration, kidney failure, electrolyte abnormalities.  Taking into consideration all these facts, the patient's complaints, results of the laboratory studies, and diagnostic tests were worrisome.  Therefore, the patient definitely required admission to the hospital for monitoring to determine the cause of her symptoms and rule out significant medical problems.  Having said that, the clinical course as well as a lack of significant findings in the imaging studies would support a lower level of care status.  There was no need for any intervention requiring admission at the acute inpatient level of care.