Diagnosis: Abdominal Pain
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a past medical history (PMH) of osteoarthritis (OA), obesity, gastroesophageal reflux disease (GERD), migraines and hypertension (HTN) and was admitted with complaints of (c/o) abdominal pain associated with nausea, vomiting and dizziness after taking new HTN medications. The abdominal pain was noted to be improving in the emergency department (ED) without any nausea or vomiting noted during the ED stay. Vital signs were notable for temperature 100.2 degrees Fahrenheit and pulse 94. The physical exam was notable for dry mucus membranes (MM), and clammy, mild generalized tenderness in abdomen without rebound/rigidity. Lab work was notable for electrolyte abnormalities, mild leukocytosis, and mild transaminitis. A chest x-ray (CXR) showed interstitial prominence, transthoracic echocardiogram (TTE) showed no significant abnormalities, right upper quadrant (RUQ) ultrasound (US) showed fatty liver disease (FLD) and an electrocardiogram (EKG) showed normal sinus rhythm (NSR) without ischemic changes. The patient was diagnosed with dehydration and gastroenteritis and treated with anti-emetics, antacids, and intravenous (IV) fluids. The patient also received cefoxitin due to potential concern for choledocholithiasis. The patient was discharged on 5/4/2019 in stable condition. At issue is the medical necessity of an inpatient stay.

The hospital stay was not medically necessary at an acute inpatient level of care. This patient presented to the ED with c/o abdominal pain associated with several episodes of nausea and vomiting. The patient did not have associated high-risk features, such as renal failure, congestive heart failure, or liver failure, nor did the patient have any hemodynamic instability. In addition, while the patient had electrolyte abnormalities, the patient responded to electrolyte repletion, nor did the patient have bowel obstruction, diabetic ketoacidosis, or appendicitis. The patient was hemodynamically stable, the pain was documented to have improved while in the ED, there was no acute kidney injury, pyelonephritis, ascending infection, toxic appearance, unstable vital signs, or immunosuppression. The patient presented with acute viral gastroenteritis with dehydration, was treated and responded to IVF, anti-emetics, one day of IV antibiotics and pain control, and these interventions could have been safely and appropriately provided at a lower level of care.