Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acid reflux

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld
 

This case involves an adult who presented to the emergency department (ED) with a chief complaint of acid reflux.  His vital signs were stable, but he claimed to have 9/10 pain.  His Glasgow coma score was 15 and he was found to have a past medical history significant for cardiovascular hyperlipidemia, depression, anxiety, Tourette's, gastroesophageal reflux disease, and hypertension.  The patient appeared uncomfortable and took medication prior to his arrival with no relief.  He complained of abdominal pain, diarrhea, and fever but claimed to have no dysuria, nausea, or vomiting.  The report stated the patient was seen in the emergency department the day prior and diagnosed with dehydration, abdominal pain, and nausea/vomiting.  The computed tomography (CT) of the abdomen/pelvis was negative, and the nausea and vomiting had resolved.  

He woke up a few hours before his arrival with severe epigastric pain that was unrelieved with Pepto-Bismol, omeprazole, and Mylanta taken 2 hours before he was seen.  Laboratory values noted that blood glucose was elevated at 116, potassium was low at 3.3, chloride was elevated at 109, with calcium low at 8.4, total protein low at 5.8, lactate elevated at 2.38, hemoglobin low at 12.5, hematocrit low at 37.7, with absolute monocyte count elevated at 1.3.  Chest x-ray noted atelectatic changes but cardio mediastinal silhouette was normal in size and configuration.  There was no evidence of pneumothorax or pleural effusion.  Azygous fissure was incidentally noted with abdominal findings on x-ray showing mild constipation with occasional nonspecific right mid and lower quadrant (large and small bowel) air-fluid levels present for which correlation is advised.  There were several tiny pelvic calcifications noted, probably reflecting phleboliths.  The patient's electrocardiogram (EKG) noted normal sinus rhythm.  The patient received intravenous fluids and reported mild relief from morphine.  The patient was subsequently admitted for further work-up and care.  

He underwent esophagogastroduodenoscopy and colonoscopy with the results noting gastritis and a small hiatal hernia along with 2 small rectal polyps.  Additional findings included a viral infection in the intestines for which he gradually improved with treatment and went home after a short hospital stay.  

According to the Milliman Care Guidelines, the patient did not satisfy the criteria for inpatient admission.  He was hemodynamically stable and while he had a small hiatal hernia, gastritis and was described as tortuous appearing esophagus, the evidence did not suggest that the patient could not receive adequate treatment on an observational basis.  He responded to intravenous therapy to include the administration of fluids and morphine.  The reported viruses were not significant and could have been treated safely and effectively without inpatient admission.  

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for inpatient admission is not substantiated.