Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

The insurer has denied coverage for an inpatient admission. In their Final Adverse Determination letter, they write that the patient was admitted to the hospital for abdominal (stomach) pain. There was no hemodynamic, pulmonary, neurological, or metabolic reason for an acute level of care. The services and interventions provided could have been done in the observation setting. There was no positive test or other findings after evaluation that would have required an acute level of care. This is based on MCG (Milliman Care Guidelines) Criteria- Abdominal Pain, Undiagnosed, 26th edition. 

The patient is appealing. In an appeal letter, they write that the patient presented to the hospital with severe and worsening abdominal pain associated with nausea and vomiting. The patient was found to have urinary retention, fever of unknown etiology, intractable pain, and tachycardia. A foley catheter was placed and the patient was admitted for a workup for fever. Pain management, an aggressive bowel regimen, a surgical evaluation, and a psychiatric evaluation were given.

The patient has a history of peptic ulcer disease (PUD), gastric bypass, diabetes, abdominal adhesions, and intussusception. The patient presented with abdominal pain, constipation, and urinary retention. In the emergency room (ER), the patient initially had tachycardia but was hemodynamically stable. The patient had a low-grade fever. There was no abdominal rebound or guarding. A computed tomography (CT) scan showed a suggestion of a small segment of intussusception in the jejunum. A fever workup was done, and the patient was given a bowel regimen. A foley catheter was inserted for the urinary retention. It was advised to avoid opioid medications. The psychiatrist advised outpatient management of anxiety. No surgical revision was advised for the intussusception, but antibiotics were given. 

Medical necessity was determined based on Milliman Care Guidelines (MCG) guideline M-05 for Undiagnosed Abdominal Pain. Clinical indications for admission include hemodynamic instability, severe pain that is not responding to analgesics, peritoneal signs, bowel perforation or obstruction, an inability to maintain oral hydration after observation care, and bacteremia. The patient did not have these conditions. 

This patient required a workup for the abdominal pain. The patient needed a foley catheter, surgical consultation, psychiatry consultation, cultures, and a bowel regimen. This could have been done with observation care. No surgical interventions were needed at this time. The patient did not meet MCG criteria for admission for Undiagnosed Abdominal Pain. The health care plan acted reasonably and with sound medical judgment. An acute inpatient admission was not medically necessary. The denial is upheld.

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 an inpatient admission is not substantiated.