Appeal type: Medical necessity
Decision: Upheld

Digestive System /Gastrointestinal - Abdominal/Stomach Pain
Inpatient Hospital

The patient is a female with a past medical history significant for diabetes mellitus, hypertension, schizophrenia, and depression who was referred from an outpatient psychiatric clinic because of abdominal distention and tachycardia.
According to the history and physical (H&P) note, the patient was a poor medical historian and was unable to provide any meaningful history. At the same time, she reported abdominal distention over the course of several weeks and stated that she vomited one day before the day of admission. The patient also stated that her last bowel movement was on the day of admission. The review of systems was otherwise negative.
At the time of the initial evaluation, the patient was found to be tachycardic. Her heart rate was 127 beats per minute (bpm) initially but subsequently went down to 88 bpm.
At the time of the initial evaluation, the patient was lying comfortably in bed in no acute distress. Her speech was incoherent, but she was able to follow commands. head, eyes, ears, nose, throat (HEENT) exam was within normal limits. Lungs were clear to auscultation without rhonchi, wheezes. The cardiovascular examination was unremarkable. The abdomen was distended but non-tender with normal bowel sounds. There was no suprapubic tenderness.
Laboratory evaluation demonstrated that the white blood cell count was 7.9, hemoglobin 12.9, hematocrit 40.0, platelets 271. Sodium was 141, potassium 4.1, chloride 108, bicarbonate 25, blood urea nitrogen (BUN) 11, creatinine 0.7, glucose 79. The lipase was 33. Liver function tests were within normal limits. thyroid stimulating hormone (TSH), free T4 was also within normal limits.
Computed tomography (CT) scan of the abdomen and pelvis demonstrated a few loops of distal jejunum in the right mid to lower abdomen. This finding was consistent with an internal hernia that was likely congenital in nature. The patient also had a few fluid-filled loops of ileum within the right mid to lower abdomen without bowel wall thickening. This transitioned to normal caliber ileum with oral contrast media. There was no bowel obstruction.
The patient was admitted to the hospital with abdominal distention of unclear etiology.
General surgery service was consulted since the admitting physician suspected that the patient could have an early small bowel obstruction.
According to the surgeon, the patient was not obstructed. The surgeon stated that the patient was constipated, and this was evident based on the CT scan images and likely related to the anticholinergic effect of psychiatric medications.
The patient was recommended bowel regimen, kidney ureter bladder (KUB) film in the morning to monitor the progress was ordered.
As a result of the aggressive bowel regimen, the patient started to have frequent bowel movements. The symptoms significantly improved, and she was discharged from the medical floor to the inpatient psychiatric unit.

The health plan's determination is upheld.

This patient presented to the hospital with abdominal distention and reported vomiting one day before the day of admission. The initial evaluation that included a physical exam, and results of the laboratory studies and diagnostic tests, did not reveal any acute medical condition necessitating admission at the acute inpatient level of care.
This patient was afebrile and hemodynamically stable. Even though she was initially tachycardic in the emergency department, her tachycardia resolved very quickly. The patient's abdomen was soft without any peritoneal signs. The laboratory studies were unremarkable. There was no evidence of acute kidney failure or significant electrolyte abnormalities, pancreatitis, or hepatitis. CT scan of the abdomen and pelvis did not show definitive signs of small bowel obstruction or any other clinical condition that would require admission at the acute inpatient level of care. Even though the patient reported vomiting one day before the day of admission, there was no evidence of significant dehydration based on the laboratory results. The patient was seen by general surgery and was diagnosed with constipation, which was most likely a side effect of her psychiatric medications.
The patient was started on an aggressive bowel regimen with a fast response to the treatment. Taking into consideration all these facts, admission at the acute inpatient level of care was not justified as medically necessary.

As indicated in the previous section of this report, neither the severity of the patient's condition that was defined by the results of the physical exam, laboratory studies and diagnostic tests nor the complexity of the services provided justified admission at the acute inpatient level of care.
The admission for monitoring to ensure clinical stability, to establish the correct diagnosis, and ensure adequate response to aggressive bowel regimen was reasonable at a lower level of care status.