Appeal type: Medical necessity
Decision: Overturned

Digestive System/Gastrointestinal
Inpatient hospital

Diagnosis: Abdominal pain
Treatment: Inpatient stay
The insurer denied the inpatient stay. The health plan's determination is overturned in part. A one-day stay was medically necessary.

The patient is a previously healthy boy brought to the emergency department (ED) with a three day history of non bilious vomiting and abdominal pain. He had been in the ED the day before for the same problem. The pain was in the upper abdomen and peri-umbilical area and did not radiate. He had loss of appetite, nausea, vomiting, and decreased oral intake. His stools were normal without blood or mucus. His urine was normal. There was no one with similar symptoms at home. There was no fever or diarrhea. At triage his blood pressure (BP) was 148/89, heart rate (HR) 88, respiratory rate (RR) 20, saturation 100% on room air, and pain 5/10. The ED physician's physical exam notes an alert and oriented boy in moderate distress with dry mucus membranes, soft abdomen with normal bowel sounds and moderate tenderness in the epigastric and peri-umbilical area without guarding or rebound. Electrolytes, blood urea nitrogen (BUN), and creatinine were normal. Amylase and lipase were normal. pH was 7.46 on venous sample. White blood cell count (WBC) was 8.5. Ultrasound was normal, but appendix was not identified. A computed tomography (CT) was normal and the appendix was identified and reported to be normal. Urinalysis showed mild proteinuria, negative heme, 4 red blood cells (RBC).

A one day stay was medically necessary. With regard to the abdominal pain, he had an extensive laboratory and radiographic workup in the ED. Surgical causes were excluded. He received substantial IV fluid in the ED, because he was nauseated and not taking po's and had dry mucus membranes. He did not have acidosis or electrolyte abnormalities and he no longer had dry mucus membranes noted on admission to the pediatric ward. To whatever extent he had a mild dehydration, that condition was corrected in the ED. Hospitalization for the abdominal pain at that point was for observation and for facilitation of a GI consult, which recommended H. pylori testing and management of functional abdominal pain, which the consultant thought was the likely diagnosis. By the end of the first hospital day, he was taking some po's and was improved from a gastrointestinal standpoint.
With regard to the hypertension, the diagnosis remained unclear. One measurement was very high, 147/103, other measurements were more modestly elevated, but still abnormally high for his age. He was started on amlodipine and blood pressures were quickly brought into a range that was not dangerous. Nephrology was consulted. Hypertension related to pain was considered. (It is noteworthy that his measured heart rate was not elevated, and patients who are in pain are typically tachycardic.) A family history of hypertension (dad) and renal disease (mom) was elicited.
This first hospital day was medically necessary due to the markedly elevated and potentially dangerous blood pressure readings. Hospitalization was required to bring the blood pressure under control and ensure there were no immediate consequences. By the 2nd day, it was clear that his hypertension was under control and further management at that point was observational.