Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gallstone and common bile duct stones. 
Treatment: Inpatient Hospital Stay. 

The insurer denied the Inpatient Hospital Stay. 
The determination is overturned. 

The patient presented to an outside hospital with upper abdominal pain and elevated liver enzymes. She had a past medical history of obesity. She was diagnosed with gallstones and common bile duct stones (choledocholithiasis). She was transferred to the current hospital due to the anticipated need for endoscopic retrograde cholangiopancreatography (ERCP) to treat the common bile duct (CBD) stones and the need for a higher level of care. 

At the time of presentation to the receiving hospital, the patient was without a fever and her vital signs were normal. The complete metabolic panel identified elevated transaminases and bilirubin. The diagnosis was that of choledocholithiasis with worsening liver enzymes. A gastroenterology consult was obtained and the patient was prepared for the ERCP to be performed. The patient was receiving intravenous (IV) fluid and she was NPO status (nothing by month). 

The patient was evaluated with an MRCP and lab data. The lab data showed an improvement in the liver enzymes and bilirubin and the MRCP showed no common bile duct (CBD) stones. The ERCP procedure was cancelled per the gastroenterology (GI) service with the clinical rationale that the CBD stone passed. She underwent a laparoscopic cholecystectomy. The operative dictation describes an uncomplicated cholecystectomy procedure. A surgical drain was placed at the time of surgery. She was started on a clear liquid diet following surgery. She was considered to be stable for discharge home with arrangements for outpatient follow up. At issue is the medical necessity of an inpatient stay. 

An inpatient level of care was medically necessary in this case and consistent with the generally accepted guidelines. 

This patient presented to the hospital with cholelithiasis and choledocholithiasis (elevated liver enzymes and bilirubin, dilated bile duct on imaging). She had appropriately been transferred from another hospital due to the need for an ERCP. It was anticipated that she would require ERCP with stone extraction and subsequent cholecystectomy and that this care would span a period of greater that 48-hours. In the course of her evaluation, it was identified that MRCP no longer identified CBD stones and the liver enzymes (previously very elevated) had improved. The ERCP was appropriately canceled and the patient was treated with a cholecystectomy. Her post-surgical course was uncomplicated. The diet was advanced. Vital signs remained normal. An inpatient designation is needed when there is: failure to achieve discharge status criteria, conversion to open surgery, severe systemic infection, care for active comorbidities, calculus or obstruction of gallbladder or bile duct and one or more of the following: hemodynamic instability, CBD obstruction diagnosed by imaging, vomiting that is severe, dehydration that is severe or persistent, severe pain, bacteremia, complications of the procedure. In this case, the submitted documentation does support that these clinical conditions (Calculus or obstruction of gallbladder or bile duct and CBD obstruction diagnosed by imaging) existed to warrant an inpatient level of care. 
This patient was treated in an expeditious and efficient manner and although the lab and imaging data support the conclusion that she passed the CBD stone, the intensity of service, the coordination of multiple medical services (GI and surgery), the diagnosis of choledocholithiasis in addition to cholelithiasis/cholecystitis support the medical necessity of an inpatient stay in this case.