Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain and Vomiting (acute cholecystitis)
Treatment: Inpatient hospital admission
The insurer denied the inpatient hospital admission.
The denial is upheld.

The patient is a male. He presented to the ED (emergency department) with abdominal pain and vomiting.

At the time of presentation, the patient was without fever and vital signs were normal. He was tender in the right upper quadrant. The WBC (white blood cell) count was normal at 10.4 K (thousand). The complete metabolic panel was without findings of biliary obstruction. BUN (blood urea nitrogen) and Creatinine were slightly elevated, consistent with dehydration. Abdominal CT (computed tomography) scan and ultrasound also showed gallstones/sludge with gallbladder wall thickening and some pericholecystic fluid.

The patient was admitted to the hospital and initially treated with intravenous (IV) fluid, antibiotics, and antiemetics. Surgery consultation was obtained. The surgical consultation states that laparoscopic cholecystectomy was planned for the following day. The records do not indicate that surgery was performed during this hospital admission. The patient was started on a liquid diet. Day three, the patient had normal vital signs. He was tolerating a liquid diet. Pain was controlled. The diet was advanced. The patient remained clinically stable and was discharged from the inpatient setting with planned short term follow up.

The material submitted for review includes the health plan denial letter that references InterQual Acute Adult Cholecystitis. This letter states there was no documentation of ascending cholangitis, biliary sepsis, need for open cholecystectomy. This letter states that the care provided could be rendered under observation level of care.

No, the inpatient hospital admission was not medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.

An inpatient level of care was not medically necessary in this case. This patient is a man who presented to the hospital with abdominal pain and vomiting. He was determined to have cholelithiasis/cholecystitis. There is no documentation of hemodynamic, pulmonary, neurological, or metabolic reason for an acute inpatient level of care. Additionally, there is no documentation of failure to achieve discharge criteria, conversion to open surgery, care for comorbidities, or any other condition requiring inpatient hospital admission. The indication for cholecystectomy was established. The records do not indicate that surgery was performed during this admission. The patient responded favorably to antibiotics and IV fluid and was stable for discharge from the hospital with planned follow up. Acute inpatient care was not medically necessary for this patient, as the care and treatment provided could have been rendered with a lower level of care. A lower level of care would have provided for ED assessment, surgical assessment and monitoring, provision of IV antibiotics and fluid, and overnight care.

There is no compelling reason why this patient could not have safely and appropriately been treated with a lower level of care with subsequent transition to outpatient care. Inpatient level of care was not medically necessary. An observation level of care would have permitted for the surgical assessment, the surgical procedure (if performed) and perioperative IV fluid, IV antibiotics, IV antiemetics, and overnight monitoring. The submitted records document that this patient was clinically and hemodynamically stable at the time of presentation. The patient was clinically stable throughout the period of monitoring as supported by the corresponding medical records.

The referenced InterQual Acute Adult Cholecystitis support that inpatient care is indicated when there is right upper quadrant pain, and systemic signs of inflammation (fever, C-reactive protein > [greater than] 10, WBC count > 10 K). Inpatient hospital admission is also indicated for acute cholangitis, common bile duct obstruction, vomiting that is severe or persistent, dehydration that is severe or persistent, hemodynamic instability, severe pain requiring acute inpatient management, signs of intestinal obstruction, bacteremia, need for percutaneous or open procedures, or other condition that requires inpatient hospital admission.

In this case, none of these indications existed to justify an inpatient level of care.