Appeal type: Medical necessity
Decision: Overturned

Diagnosis Abdominal Pain
Treatment Inpatient stay
The insurer denied the Inpatient stay
The determination is overturned.

The patient presented to the emergency department with complaints of abdominal pain, nausea, vomiting, and diarrhea that had been going on for several days. Reportedly, the patient was unable to eat since her symptoms started and could only tolerate some fluid.
One day before the presentation to the emergency department she went to an urgent care center, where she was found to have a fever up to 103.4 degrees Fahrenheit (F). At that time, she was diagnosed with acute gastroenteritis. She came to the emergency department because of the worsening of her abdominal pain.
In the emergency department, the patient received several doses of anti-emetics and pain medications intravenously without much relief of her symptoms.
Vital signs were temperature 99.3 degrees, heart rate 93, respiratory rate 18, blood pressure 110/54, and oxygen saturation 98%.
On the physical exam, the patient was awake, alert, in no acute distress. Her head, eyes, ears, neck, throat (HEENT) exam was within normal limits. She had moist mucous membranes. Her lungs were clear to auscultation bilaterally without wheezes, rales, or rhonchi. The abdomen was soft, with some tenderness without guarding or rebound. The neuro exam was unremarkable.
A urinalysis was positive for leukocyte esterase; otherwise it was negative. The patient underwent a pelvic ultrasound which was interpreted as an unremarkable study. A computed tomography (CT) scan of the abdomen and pelvis revealed mild to moderate pancolitis.
The patient was admitted to the hospital with a diagnosis of pancolitis, which was thought to be infectious, possibly viral. It was indicated that the patient was unable to tolerate oral intake and had intractable pain requiring parenteral pain medications. The patient was started on intravenous fluids, pain medications, and antiemetics. She was also started on a clear liquid diet.
During the hospital stay, the patient was seen by a gastroenterologist who suggested that the patient's pancolitis was likely infectious, but inflammatory bowel disease was on the list of the differential diagnoses. The gastroenterologist recommended the continuation of treatment with intravenous fluids, intravenous antibiotics such as Ciprofloxacin and Metronidazole, and intravenous Pepcid.
Reportedly, on the next day after admission overnight, the patient developed chest pain that prompted activation of the rapid response team. The chest pain was atypical and did not require any further testing. In general, on the next day after the day of admission, the patient was feeling similar. She still had problems keeping food down due to nausea. She denied a fever, chills, vomiting, or shortness of breath. It was indicated that the patient still required the administration of parenteral pain medications. She received 2 milligrams (mg) of intravenous morphine as needed every 4 hours. The patient continued to receive treatment with intravenous antiemetics as well as antibiotics. Stool culture was sent.
The patient's condition somewhat improved, including diarrhea. She had some personal issues at home and elected to leave the hospital against medical advice. At issue is the medical necessity of an inpatient stay.

The acute inpatient admission was medically necessary at the acute inpatient level of care.
The patient had fairly severe symptoms that persisted for several days before admission and did not improve. At the time of the initial evaluation she had a fever, the symptoms persisted, she was unable to keep anything down. While in the hospital, she still complained of nausea, diarrhea, and abdominal pain, despite the administration of antibiotics and pain medications.
Another clinical problem was diminished oral intake, which would jeopardize the effectiveness of treatment with oral antibiotics that could be used to treat the pancolitis. In addition, persistent fluid losses from the gastrointestinal tract could lead to dehydration and electrolyte abnormalities. Because of persistent nausea, the patient required treatment with parenteral antibiotics for the treatment of possible infectious pancolitis. For the same reasons, she required frequent administration of intravenous antiemetics, pain medications.
Considering all of these circumstances, admission at the acute inpatient level of care was medically necessary as it was the most efficient way to provide treatment, ensure adequate hydration and hemodynamic stability, and determine the reason for the patient's pancolitis.