Diagnosis: Epigastric pain and nausea
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld

The patient is an adult male patient who had a history of hemorrhoids. The patient reported a month history of intermittent epigastric pain associated with nausea and emesis. The patient had undergone several outpatient evaluations with no significant findings and supportive therapy recommendations. Antecedent to this admission, the patient had episodes of watery diarrhea, abdominal discomfort, and fevers to 103 degrees - as per the patient. The patient had an isolated leukocytosis of 17.1.
In the emergency department, the patient evidenced hemodynamic stability. Right lower quadrant tenderness was noted on physical exam. A computed tomography scan showed possible enterocolitis of the terminal ileum and colon. The patient received supportive care including intravenous fluid and antibiotics for the treatment of the diagnosis of Yersinia enterocolitica. The patient responded to treatment and cultures were negative on discharge.

The proposed inpatient hospital admission was not medically necessary.

The evaluation and treatments as rendered were medically appropriate; however, the level at which the care was provided was not medically necessary. Despite the patient's presentation, the care as provided could have been rendered in its entirety at
a lower level of care. This patient had a gastrointestinal infection; yet he did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for nothing by mouth status, need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias, failure of outpatient therapy or any other indication for an acute admission. As such, the care could have been rendered at a lesser level.