Digestive system
Inpatient hospital

Diagnosis: abdominal pain.
Treatment: Inpatient stay.
The insurer denied the inpatient stay.
The health plan's determination is overturned.

The patient was a male with medical history of gastric ulcer complicated by perforation status post-surgical repair, anemia, and intravenous heroin addiction treated with methadone. He presented to the emergency department with abdominal pain unrelieved by medication and heroin, nausea, vomiting, loss of appetite, shaking, restlessness, chills, and chest pain. He was using heroin daily, with most recent use on the prior day. Vital signs were notable for elevated blood pressure of 145/93. Physical examination was notable for generalized and epigastric abdominal tenderness. Labs showed elevated white blood cell count of 11.6 with 80% neutrophils, low sodium of 135, and elevated calcium of 10.5. Urinalysis was notable for 2+ (plus) ketones, 3 white blood cells per high-power field, and negative leukocyte esterase. Computed tomography scan of the abdomen and pelvis showed a large amount of stool in the colon, no extraluminal air or intraperitoneal fluid to suggest duodenal perforation, and no evidence of intra-abdominal pathology to explain his pain. He was treated with intravenous fluids.

The inpatient level of care was medically necessary. The patient presented with symptoms of opioid withdrawal, including abdominal pain, in the setting of history of peptic ulcer disease complicated by perforation. He was treated appropriately with monitoring and buprenorphine, but had risk of complications of withdrawal. The inpatient level of care was more appropriate than observation care for monitoring. He did not have resolution of withdrawal signs and symptoms until two days after presentation. For these reasons, the inpatient level of care is supported in this case.