Diagnosis: Abdominal Pain
Treatment: Inpatient admission
The insurer denied coverage for the inpatient admission.
The denial is upheld.

The patient presented with abdominal pain. The patient was afebrile, and the vital signs were stable. The abdominal exam was benign. There was no leukocytosis. An abdominal Computed Tomography scan showed a mildly dilated appendix but no fluid collection. The pain rapidly resolved, and the patient was able to tolerate a diet. The gastroenterologist advised that the patient did not have acute appendicitis, but that gastritis was possible.

Clinical indications for admission for Undiagnosed Abdominal Pain (Milliman Care Guidelines M-05) include hemodynamic instability, peritoneal signs, inability to maintain oral hydration after observation care, bacteremia, and the need for a procedure that cannot be performed on an ambulatory basis. The patient did not have these conditions.

This patient had abdominal pain. Although the appendix was mildly dilated, the clinical picture was not consistent with acute appendicitis. Intravenous hydration, antiemetics, and Proton Pump Inhibitor therapy could have been given in the Emergency Room with observation status. The patient's symptoms rapidly improved and the patient did not require any surgical interventions. The patient did not meet Milliman Care Guidelines criteria for admission for Undiagnosed Abdominal Pain.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for inpatient admission is not substantiated.