Diagnosis: Abdominal Pain.
Treatment: Inpatient admission.
The insurer is denied coverage for inpatient admission. The denial is upheld.

This is a female patient with a history of morbid obesity, fatty liver and lap band surgery. The patient presented to the Emergency Department (ED) with complaints right upper quadrant (RUQ) pain and vomiting after eating. Upon arrival to the ED, the patient was afebrile, heart rate (HR) 117, respiratory rate (RR) 22 and blood pressure (BP) 170/109 with a pulse oximetry of 100% on room air (RA). The patient recently started gaining weight, and the patient was evaluated on an outpatient basis with manipulation of saline in the port. An ultrasound was done and revealed an enlarged liver with steatosis and no gallstones. The patient's labs were essentially unremarkable except for elevated glucose. The patient was admitted to the hospital and made nothing by mouth (NPO). Intravenous (IV) fluids were given. An abdominal x-ray, upper gastrointestinal (UGI) series were performed; the UGI series was negative and the abdominal X-ray showed non-specific bowel pattern. The Hospitalist service was consulted.

The patient requested that the lap band be removed during this admission as the lap band was most likely the etiology of her presenting symptoms. A Hospitalist note indicated that the patient's abdomen was soft, non-tender with normal bowel sounds. The patient's UGI report indicated gastric band in stable position without obstruction with no abnormal narrowing of the lumen at the level of the band. The recommendation was to control hyperglycemia. Cardiology saw the patient and cleared the patient for surgery. Pulmonary saw the patient and also cleared the patient for surgery. A progress note indicated that the patient was sitting comfortably in bed. The patient denied chest pain or shortness of breath (SOB); denied abdominal pain, nausea or vomiting. The patient was taken to the Operating Room (OR) and underwent an uneventful diagnostic laparoscopy, lysis of adhesion, removal of lap band and esophagogastroduodenoscopy (EGD). The patient's findings included esophagitis and no iatrogenic perforation to the stomach and no gastric outlet obstruction. A progress note indicated that the patient was doing well, tolerating diet and was to be discharged home with instruction to maintain a liquid diet for two days and then transition to a soft diet.

The health plan acted reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the acute inpatient admission should be upheld. The medical necessity is not substantiated.