Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain, abdominal pain, nausea
Treatment: Inpatient Hospital Admission
The insurer denied Inpatient Hospital Admission.
The denial is upheld.

This patient is an adult male who presented to the hospital with chest pain, abdominal pain, nausea, diarrhea, and vomiting with blood-streaked contents. The patient had a past history of hypertension, hyperlipidemia, diabetes mellitus, and coronary artery disease. In the emergency room, the patient was given intravenous pantoprazole, magnesium sulfate intravenous, potassium chloride, nifedipine, labetalol, and Zofran intravenous. X-ray of the abdomen showed nonspecific non-obstructive bowel gas pattern. Computed tomography (CT) of the abdomen/pelvis showed infrarenal aneurysm aortic aneurysm 3.7 by 3.7 centimeters and a small amount of hyperdense material within the stomach. The patient was admitted to inpatient setting for further management and evaluation. Gastroenterology (GI) was consulted. The thought was that the patient had an esophageal injury from multiple episodes of vomiting versus Mallory Weiss syndrome. Hemoglobin (Hgb) was 14-15 and there was no hemodynamic compromise. No endoscopic evaluation was recommended. The patient was ruled out for acute coronary syndrome. Echocardiogram was completed and showed mild aortic valve regurgitation and mild aortic root dilatation. The ascending aorta was moderately dilated. The thought was that the chest pain was likely due to musculoskeletal, improved with conservative management. The gastrointestinal symptoms were believed to be secondary to gastritis in the setting of chronic non-steroidal anti-inflammatory drug (NSAID) use, viral gastroenteritis, or foodborne illness. An emergency department progress note states, "No more hematemesis or vomiting during this shift. Tolerated diet. No need for EGD (esophagogastroduodenoscopy) per Gl (gastroenterologist) /continue with PPI (proton-pump inhibitors). Uncontrolled blood pressure despite initiation of nifedipine and labetalol. Started on nitroglycerin gtt. will be sent to red zone. Upgraded to medicine telemetry. Labs repeated and/H&H (hemoglobin and hematocrit) stable." On day # (number) 4, the patient tolerated regular meal at lunch. Chest and shoulder pain improved. The patient still had neck pain. The patient was discharged on day # (number) 5.

The proposed treatment was not medically necessary.

The medical records do not support that the acute inpatient admission was medically necessary. The patient did not require services of such intensity that could have been safely and effectively provided only on an inpatient level of service. The health, safety, and medical condition of the patient would not have been threatened by providing the care given in a lower level of care setting. An observational level of stay would have been more appropriate for this patient. An observational level of stay would have been a more efficient setting, since the patient did not require any procedural or surgical intervention, did not require to be nothing by mouth for a prolonged duration of time, did not require prolonged treatment with intravenous hydration or intravenous medications and did not have any complications such as intra-abdominal abscess or a surgical abdomen. The patient did not have hemodynamic instability, severe pain requiring acute inpatient management, or peritoneal signs. The patient did not require identification of etiology or finding or evaluation requiring the patient to not eat or drink for extended period (e.g., more than 24 hours). The patient did not have an inability to maintain oral hydration (e.g., needs intravenous fluid support) that persisted after observation care; and did not have suspected toxic megacolon. The patient did not have bacteremia. The patient did not require a procedure that could not have been performed on ambulatory basis.