Diagnosis: Abdominal pain and vomiting
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission.
The denial is upheld.

The patient has a history of Crohn's Disease, Celiac Disease, bowel resection, and fibromyalgia. She presented with abdominal pain and vomiting. She was afebrile and the vital signs were stable. There was no abdominal rebound or guarding. Computerized tomography (CT) scan showed a fluid collection and ovarian cyst. A Gynecological consult was obtained. Magnetic resonance imaging (MRI) showed a multicystic right adnexal lesion. No surgical interventions were advised at this time. It was felt that the patient did not have a flare of Crohn's Disease. An outpatient workup was advised.

Medical necessity was determined using Milliman Care Guidelines (MCG) M-05 for Undiagnosed Abdominal Pain. Clinical indications for admission include hemodynamic instability, peritoneal signs, intestinal obstruction or perforation, bacteremia, and an inability to maintain oral hydration after observation care. The patient did not have these conditions.

This patient had abdominal pain. She did not have intestinal obstruction or a flare of her IBD (inflammatory bowel disease). She was diagnosed with a multicystic adnexal lesion and required a magnetic resonance imaging (MRI) and Gynecological evaluation. However, this could have been done with observation care. No acute interventions were needed. She did not meet Milliman Care Guidelines (MCG) 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.