Diagnosis: Digestive system /gastrointestinal /abdominal pain.
Treatment: Inpatient hospital.

The insurer denied the entire inpatient stay. The denial is upheld in whole.

This is a patient with a history of chronic obstructive pulmonary disease (COPD) and chronic hepatitis C, who presented to hospital with abdominal pain and melena.

No, the requested health service/treatment of inpatient stay is not medically necessary for this patient. This patient with COPD and chronic hepatitis C presented with abdominal pain and melena. On presentation, the patient was hemodynamically stable without fever, tachycardia or hypotension. Bloodwork did not reveal leukocytosis, anemia or significant electrolyte derangements. The patient's CT abdomen/pelvis revealed liver lesion and enteritis.

The patient was admitted and treated with intravenous fluid hydration and pain control. The patient 's EGD revealed esophageal varices, portal hypertensive gastropathy and duodenal ulcer. Colonoscopy revealed terminal ileitis and colon polyps. He was initiated on therapy with a proton pump inhibitor. This patient remained hemodynamically stable and did not have ongoing overt gastrointestinal bleeding or require transfusion with packed red blood cells or require endoscopic or surgical intervention to the stop the bleeding in this case.

According to the Milliman Care Guidelines (MCG) guidelines, as the patient did not have active bleeding, high risk endoscopic features, severe liver disease, significant active comorbid disease, previous aortic graft placement, coagulopathy, syncope, associated condition requiring hospitalization, hemodynamic instability, complicated anemia, severe pain requiring acute inpatient management, high risk low platelet count, requiring intravenous fluid administration, or immediate surgery, an acute inpatient level of care and inpatient admission was not medically necessary.