Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Small bowel obstruction. 
Treatment: Full hospital admission. 
The insurer denied coverage for the full hospital admission. 
The denial is overturned. 

This is a male patient with no known past medical history who presented to the Emergency Department (ED).  As per the ED provider note, the patient was sent from a renal clinic for evaluation of electrolyte imbalance/ renal insufficiency.  He was seen in the ED three days prior.  Complete metabolic panel (CMP) showed  blood urea nitrogen (BUN) 108 and creatinine 2.5.  The patient stated he had not seen a doctor in years on his visit to the ED for chronic abdominal pain, vomiting, diarrhea.  Today he was afebrile with blood pressure (BP) 136/66. Exam revealed no distension to the abdomen which was soft and without tenderness. There was a large right inguinal hernia.  The assessment was chronic abdominal pain, renal insufficiency, large right inguinal hernia.  The plan was intravenous (IV) fluids and abdominal x-ray. Abdominal x-ray showed dilated loops of bowel with suspected wall thickening which could represent ileus or possible enteritis.  Computed Tomography (CT) of the abdomen with contrast showed larger right inguinal hernia which may contain proximal transverse colon; there was thickening and irregularity of the loop of transverse colon which was contained within the hernia sac; Superimposed infection, ischemia or new mass cannot be excluded.

As per an ED note "patient has SBO [small bowel obstruction], and surgery was seeing the patient.  The patient denies complaints of pain or discomfort at this time."

As per the History & Physical (H&P), the patient has a long standing right sided scrotal hernia that is non reducible but does not bother him.  It has been present for many years and it has been the same size without recent changes.  The patient states that he typically has intermittent difficulty with bowel movements but typically has two bowel movements a day. However a week prior, he suddenly noted very watery diarrhea and anything he took down resulted in watery bowel movements.  He also reported intermittent blood in his stool prior to that but noted bloody movements along with the diarrhea.  He presented to the ED due to nausea and vomiting and diarrhea.  Kidney, ureter, and bladder (KUB) x-ray showed dilated loops of small bowel and electrolyte abnormalities.  He was hydrated and with improved exam, and was sent home to follow up with Gastroenterology (GI).  

The inpatient acute care was clearly indicated and warranted as the patient had SBO documented on CT with a transition point noted with fecalization of small bowel contents concerning for obstruction.  He needed to be brought into the hospital for management.  Unfortunately, he signed himself out against medical advice (AMA) prior to follow through whether or not there was true obstruction.  He did have a large right inguinal hernia which could have led to all of this.  But this needed to be determined.  The safe and prudent thing was to admit the patient and monitor with serial exams and to do x-rays studies as planned.  

The inpatient admission in this case was appropriate and observation/ ambulatory was not appropriate. The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The inpatient admission was justified and if the patient had not signed out AMA he would have been there longer for management and determination if any surgical intervention was warranted.  This patient had SBO, and the patient needed to be admitted and made nothing by mouth (NPO) and given IV fluids which is the appropriate treatment.  The fact that he left AMA should not come into the decision making for justification of admission.  

The insurer's denial of coverage for the full hospital admission is overturned. Medical Necessity is substantiated.