Diagnosis: Abdominal Pain
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

This is a patient with a past medical history (PMH) of a small bowel obstruction (SBO) who was admitted with complaints of (c/o) a 24-hour history of abdominal pain associated with emesis. His vital signs were unremarkable. The physical exam was notable for abdominal tenderness to palpation (TTP), positive (+) guarding. Lab work was unremarkable. A computed tomography (CT) scan of the abdomen/pelvis showed findings consistent with (c/w) SBO involving the distal ileum. The patient was diagnosed with adhesive SBO and treated with non-operatively with nothing by mouth (NPO), intravenous fluids (IVF), nasogastric (NG) tube, surgery evaluation, and serial abdominal exams. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient stay.

The hospital stay was medically necessary at an acute inpatient level of care.

This patient presented to the emergency department with complaints of abdominal pain associated with nausea and vomiting. He was found to have a small bowel obstruction on radiography evaluation, and was admitted for urgent surgical consultation and close observation. All patients with suspected/confirmed intestinal obstruction should be admitted with early surgical consultation, especially in this patient with a prior history of SBO. Such patients require hospital admission for resuscitation, decompression, serial abdominal examination, and possibly operative therapy. Overall, this patient's clinical presentation, and clinical concern for acute surgical abdomen, required the patient to have an acute inpatient level of care for safe treatment and monitoring.