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 Wegener's granulomatosis on steroids and was admitted with complaints of (c/o) abdominal pain associated with nausea and vomiting and back pain after a fall. The vital signs were notable for a pulse of 100. The physical exam was notable for oral thrush, left dacryocystitis, and abdominal tenderness. Lab work was notable for evidence of a urinary tract infection (UTI). A chest x-ray (CXR) showed patchy bilateral airspace opacities suspicious for pneumonia. An electrocardiogram (EKG) showed sinus tachycardia. The patient was diagnosed with pain likely secondary to a fall and treated with pain control, antibiotics, and a radiologic work-up. The patient was discharged 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(emergency room) with c/o abdominal pain associated with nausea and vomiting and back pain after a fall. 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, the patient did not have a bowel obstruction, diabetic ketoacidosis, or appendicitis. The patient was hemodynamically stable, the tachycardia improved, and she did not have an acute kidney injury, pyelonephritis, ascending infection, toxic appearance, or unstable vital signs. Although there was a suggestion of possible pneumonia on the admission CXR, the patient's CURB-65 [confusion, urea, respiratory rate, blood pressure, age greater than or equal to 65] score was zero and was considered low-risk. The patient presented with musculoskeletal pain after a fall, was treated and responded to physical therapy (PT), antibiotics, and pain control, and these interventions could have been safely and appropriately provided at a lower level of care.
Per the Milliman Care Guidelines (MCG) for Abdominal Pain, Undiagnosed, the patient did not have hemodynamic instability, severe pain requiring acute inpatient treatment, peritoneal signs, need for prolonged nothing by mouth (NPO), suspected toxic megacolon, bacteremia, or need for inpatient procedure.