Diagnosis: Digestive System/ Gastrointestinal.
Denial: Inpatient stay.
The health plan's determination is upheld in whole.

The patient has a medical history of spinal stenosis, chronic constipation, hypothyroidism, and open umbilical hernia repair with mesh who presented to the emergency department with abdominal pain for several months and nausea. Patient reported two days of severe periumbilical stabbing abdominal pain, loss of appetite, chills, anorexia, diarrhea, nausea, vomiting, and a gait problem. Vital signs were notable for tachycardia with pulse rate of 101/minute. Examination was notable for an ill appearance, periumbilical abdominal tenderness, and abnormal gait. Labs showed elevated blood urea nitrogen of 22 mg/dL. Computed tomography scan of the abdomen and pelvis showed partial/low-grade small bowel obstruction, small bowel wall thickening involving the dilated segments representing inflammation/enteritis, and less likely ischemia. patient was made nil per os and was treated with intravenous fluids and morphine. Surgery consultation noted that there was likely enteritis, lack of obstruction, and no indication for surgical admission or intervention. Gastrointestinal pathogen panel was negative. Patient felt better, with improving abdominal pain and lack of nausea and vomiting; was tolerating clear liquids. Labs showed low hemoglobin of 11.1 g/dL. On day of discharge abdominal pain had resolved, patient had one bowel movement; denied nausea and vomiting, and was asking to advance the
diet.

The inpatient level of care is not supported in this case. The patient presented with abdominal pain, nausea, and vomiting consistent with gastroenteritis or bowel obstruction, and imaging consistent with partial small bowel obstruction. The standard of care for uncomplicated partial small bowel obstruction, including intravenous fluids, serial abdominal exams, nil per os status with gradual advancement of diet, and monitoring of labs was performed, and all could have been performed without the inpatient level of care [1-3]. The standard of care for the treatment of gastroenteritis was also appropriately performed, including intravenous fluids and supportive care, and symptoms improved [4-6]. There was no protracted fever or hypotension to suggest uncontrolled infection. No other cause for the inpatient level of care, such as peritonitis, abscess, perforation, fistula, toxic megacolon, sepsis, or other complication was documented. Observation, monitoring, labs, and specialist consultation could have been performed without the inpatient level of care, at a lower level of care. For these reasons, the inpatient level of care is not supported in this case.