Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain. 
Treatment: Inpatient Admission. 
The insurer denied the inpatient admission. 
The health plan's determination is upheld. 

The patient is a female with a past medical history significant for hypertension, status post cholecystectomy who presented to the hospital with complaints of acute onset of right-sided abdominal pain that began just several hours before her presentation. Until then she was in her usual state of health. The patient stated that her abdominal pain radiated to the back. It was severe initially, but by the time the patient was seen by the admitting physician she rated the pain as a 3 out of 10 in severity. The patient also said that the pain migrated to the right lower quadrant. She was unable to identify any modifying factors and also complained of mild nausea and shortness of breath secondary to pain. She denied vomiting. Her last bowel movement was 2 days before her presentation, but she passed flatus. 

When the patient was seen by the admitting physician, she was afebrile. Heart rate was 65 beats per minute (bpm), respiratory rate 15 breaths per minute, blood pressure 131/72 and her oxygen saturation was 100 percent (%) on room air. The patient was lying in bed comfortably and in no acute distress. The head, eyes, ears, neck, throat (HEENT) examination was within normal limits. The patient's neck was supple without lymphadenopathy, masses, jugular vein distention (JVD), and carotid bruits. The patient's lungs were clear to auscultation without wheezes, rales, or rhonchi. The patient had a regular heart rate and rhythm, without murmurs, rubs, or gallops. The patient's abdomen was soft and nondistended. Bowel sounds were present in all 4 quadrants. There was right lower quadrant tenderness on palpation. There were normal peripheral pulses and brisk capillary refill with no clubbing, cyanosis, or edema. The neurologic examination was unremarkable. 

The computed tomography (CT) scan of the abdomen and pelvis demonstrated no acute abdominal or pelvic abnormality and a fatty liver was seen. There was persistent thickening of the endometrial complex. An endometrial biopsy was recommended. The patient was admitted to the hospital with right-sided abdominal pain, endometrial hyperplasia, hypertension, and abnormal transaminases. 

The hospital stay was not medically necessary for this patient at the acute inpatient level of care. The patient presented to the hospital with abdominal pain and was found to have elevated transaminases. Neither the results of the physical examination nor the diagnostic studies or laboratory tests were suggestive of the presence of acute cholangitis, acute cholecystitis, calculus, or obstruction of the common bile duct. The patient's symptoms were not associated with hemodynamic instability, severe or persistent vomiting, severe or persistent dehydration, or severe pain requiring acute inpatient management. The patient's symptoms improved within a short period of time, and the patient tolerated her diet. 
The patient's abdominal pain was not associated with hemodynamic instability or peritoneal signs. There was no evidence that the abdominal pain 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 abdominal pain did not require the patient not to eat or drink for an extended period of time. 

This patient remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care. The hospital stay was within the scope of an alternate level of care. 

The health plan's determination of medical necessity is upheld in whole.