Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain; Nausea.
Treatment: Inpatient admission.

The insurer denied the inpatient admission.  The denial is upheld. 

The patient is a woman. She presented to the hospital ED (emergency department) with abdominal pain and nausea of several days duration.

At the time of presentation, the patient was without fever, and her vital signs showed a blood pressure of 128/92 mmHg (millimeters of mercury) and heart rate of 87/minute.  She was tender in the right upper abdomen.  The WBC (white blood cell) count was normal at 6.7 K (thousand).  The complete metabolic panel identified normal serum transaminases, bilirubin, and alkaline phosphatase.  Ultrasound showed gallstones, but no gallbladder wall thickening or pericholecystic fluid.  Intra and extra-hepatic ducts were not dilated.

The patient was initially treated with IV (intravenous) fluid, pain medications and antiemetics.  She was treated with laparoscopic cholecystectomy.  The operative dictation and the anesthetic record describe an uncomplicated cholecystectomy procedure.

The patient was treated with post-surgical monitoring, IV (intravenous) fluid, IV (intravenous) analgesia, and antiemetics.  The immediate post-surgical recovery was uncomplicated.

Following surgery, the patient had stable vital signs.  Pain was controlled.  The diet was advanced.  The patient remained clinically stable and was discharged from the inpatient setting.

The health plan denial letter references MCG (Milliman Care Guidelines) 24th edition Cholecystectomy by laparoscopy and states that vital signs were normal, the patient was able to eat, and pain was controlled with medication.  Per this letter, an observation level of care would have been appropriate.

No, the Inpatient admission was not medically necessary.

This patient is a woman who presented to the hospital with 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, procedural complications, or any other condition requiring inpatient admission.  Acute inpatient care was not medically necessary for this patient, as the care and treatment provided could have been rendered in the observational setting.  An observational level of care would have provided for ED (emergency department) assessment, surgical assessment, imaging with ultrasound, perioperative care and monitoring, cholecystectomy as performed, provision of IV (intravenous) fluid and medication, and overnight care.

There is no compelling reason why this patient could not have safely and appropriately been treated at the observation level of care. Based on the submitted clinical documentation, an inpatient level of care was not medically necessary. This patient was admitted to the hospital with the diagnosis of cholelithiasis/cholecystitis. This patient was clinically and hemodynamically stable at the time of presentation. The WBC (white blood cell) count was normal. Serum chemistries identified normal transaminases. Her presurgical assessment and the indication for surgery was established on the date of admission. The patient underwent an uncomplicated laparoscopic cholecystectomy procedure the next day. There were no peri-operative complications or other clinical issues. She remained stable and was discharged from the hospital one day after surgery.

Inpatient level of care was not medically necessary in this case. Inpatient stay may be needed for failure to achieve discharge status criteria, conversion to open surgery, systemic infection, care for active comorbidities, complications of procedure. In this case none of these conditions existed to warrant an inpatient admission.

An observation level of care would have permitted for the pre-surgical assessment, the surgical procedure and perioperative IV (intravenous) fluid, IV (intravenous) antibiotics, IV (intravenous) antiemetics, and post-surgical monitoring. The patient was clinically stable following surgery as supported by the corresponding medical records.

The referenced MCG (Milliman Care Guidelines)- Cholecystectomy by laparoscopy, Inpatient and Surgical Care 24th edition state that inpatient care is indicated when there is right upper quadrant pain, and systemic signs of inflammation (fever, C-reactive protein > 10, WBC [white blood cell] count > 10 K [thousand]). Inpatient 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 admission.

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