Diagnosis: Abdominal pain.
Treatment: Inpatient Hospital Admission.
The insurer denied: Inpatient Hospital Admission.
The denial is upheld.

This patient is an adult male with prior colon resection surgery due to trauma who presented with lower abdominal pain, loose watery stool, inability to tolerate oral intake (POs) for 2 days.
The patient was hemodynamically stable. The white blood cell (WBC) count was 10.1. Computed tomography (CT) of the abdomen / pelvis showed dilated loops of small bowel with no definitive transition point indicating partial small bowel obstruction. The patient was treated with nothing by mouth (NPO), intravenous fluids, and Ketorolac. Surgery consult opined that there would be no surgical intervention required. On day #3, the patient felt better, abdominal pain resolved, and the patient had 2 loose bowel movements. Clear liquids were tried and the patient was discharged.

The proposed treatment was not medically necessary.

Acute inpatient level of care was not appropriate for this patient. A lower level of care would have been a more efficient setting, since the patient did not require any procedural or surgical intervention, did not require to be nothing by mouth for a prolonged duration of time, did not require prolonged treatment with intravenous hydration or intravenous medications, did not have acute kidney injury, did not have electrolyte derangement needing intravenous replacement, and did not have any complications such as intra-abdominal abscess or a surgical abdomen. The medical records do not support that the acute inpatient admission was medically necessary. The patient did not require services of such intensity that could have been safely and effectively provided only on an inpatient level of service. The health, safety, and medical condition of the patient would not have been threatened by providing the care given in a lower level of care setting. Therefore, based on review of the submitted medical records, the requested inpatient level of care was not medically necessary for the dates of service in question as it exceeded in scope and intensity the level of care necessary to provide safe, adequate and effective treatment for this patient's condition.