Diagnosis: Abdominal Pain (atelectasis).
Treatment: Inpatient Admission.

The insurer denied the inpatient admission.
The denial is upheld.

The patient is a female with history of diverticulosis, anxiety, and IBS (irritable bowel syndrome). She presented to emergency room with worsening abdominal pain. The patient had tried and failed outpatient therapy with oral pain meds and oral antibiotics. The pain was severe and uncontrollable.

The patient was admitted to hospital for the management of intractable abdominal pain as well as hypoxia. The patient received 2L (two liters) NC (nasal cannula), as well as pain medication, as needed.

The admission was denied by the health plan for lack of medical necessity. This is being appealed.

No, the Inpatient admission was not medically necessary.

The patient was admitted to acute inpatient level of care for hypoxia and abdominal pain. The emergency room work up did not reveal any abdominal abnormalities. By day two, patient was not in any distress. The patient's oxygen levels remained above 90% on room air. The patient was tolerating oral diet and was capable of ambulation. The patient was not on any invasive drips. Thus, the entire admission from was not medically necessary.