Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal Pain.
Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.  The denial is overturned.

This case involves a patient with a subject for review for the denial of coverage for inpatient hospital admission. Upon arrival at the emergency department (ED), the patient was screaming for pain medication. The patient's vital signs were blood pressure (BP) 146/88, temperature (T) 35.5 (degree) Celsius (C), oxygen (O2) saturation 100% (percent) on room air (RA). On examination, the patient was chronically ill appearing and disheveled. The patient's exam was remarkable for coarse breath sounds with scattered rhonchi, and diffuse abdominal tenderness with guarding noted. In the ED, the patient was anxious, irritable, and belligerent. Lab studies showed a potassium (K) of 3.1 and glucose of 170. Urine toxicology was positive for cocaine and oxycodone. An electrocardiogram (EKG) showed sinus rhythm at 78 and borderline long QT interval. A computed tomography (CT) abdomen/pelvis showed findings compatible with acute on chronic ascending, transverse and descending colitis, distribution favoring infectious or inflammatory etiologies. The patient received sodium chloride 0.9% 1-liter (L) intravenous (IV) bolus, lactated ringers (LR) at 75 milliliters (ml)/hour (hr), famotidine 20 milligrams (mg) IV, ketorolac 30 mg, and ondansetron IV.

According to the history and physical, the patient reported severe abdominal pain and vomiting that was non-bloody. The patient had no exacerbating or relieving factors. The patient was given Zofran in route to the ED by emergency medical services (EMS) and reported no improvement in symptoms. 

The request was previously denied due to the medical necessity having not been established. 

In this case, the patient presented to the ED from home via EMS with complaints of severe abdominal pain, nausea, vomiting, and diarrhea. The patient stated that they vomited too many times the night prior to presentation and had diarrhea. Admission was recommended for possible acute colitis with severe pain with persistent vomiting. 

The patient was seen, and gastroenterology (GI) recommended IVF (intravenous fluids) and antibiotics. The patient's white blood cell (WBC) count was 14.8, and the patient remained afebrile, continued to complain of abdominal pain, and received diphenhydramine, metoclopramide, potassium chloride, methylprednisolone, and morphine. During the consultation, the patient reported taking cocaine 3 days ago, then ate spicy food that worsened their pain.

The following day, the patient was on a clear diet, but the patient stated that they had been eating crackers and tolerating it. No nausea was reported, and the patient threatened to leave in morning, if they did not get their meal tray in the morning. The patient was ambulating on the unit, agitated and refusing meds and wanting to go against medical advice (AMA). Despite efforts, the patient refused to complete treatment course, and left the hospital AMA. 

Based on the review of records, the patient presented for severe abdominal pain, nausea, vomiting, and diarrhea. CT abdomen/pelvis showed findings compatible with acute on chronic ascending, transverse and descending colitis, distribution favoring infectious or inflammatory etiologies. The MCG indicates admission for abdominal pain that persists despite observation care. The patient arrived at the ED screaming for pain and the next day continued with complaints of abdominal pain. The patient had persistent abdominal pain that continued on day # (number) 2, despite acetaminophen and oxycodone. As such, the denial of coverage for inpatient hospital admission is overturned and is considered medically necessary.

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for inpatient hospital admission is substantiated.