Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal Pain
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is overturned.

The patient is an adult male who presented to the emergency department (ED) with abdominal pain. The patient's past medical 
history included hypertension, sleep apnea, morbid obesity (body mass index [BMI] 45 kilograms per meter squared [kg/m2]). At the time of presentation, the patient was without fever and vital signs identified elevated blood pressure (190/120 millimeters of mercury [mmHg]). The patient was tender in the right upper abdomen. The white blood cell (WBC) count was elevated at 14 thousand (K). The complete metabolic panel identified normal liver enzymes and normal bilirubin. Abdominal ultrasound and computed tomography (CT) scan showed gallstones within the gallbladder and gallbladder wall thickening. The common bile duct was 9-millimeters (mm) in diameter. The patient was admitted to the hospital with the diagnosis of cholecystitis. The patient was evaluated with surgery consultation. He was treated with antibiotics in anticipation of cholecystectomy. Follow up lab data on the next day identified leukocytosis of 15 thousand (K). The patient reported feeling better on day #2 and a diet was trialed. He had recurrent abdominal pain following a meal. The patient underwent laparoscopic (robotic assisted) cholecystectomy on day #3. The operative note describes an acutely inflamed gallbladder with stones. A surgical drain was placed in the gallbladder fossa. The operation was completed without complication. The diet was advanced following surgery. On day #4 the patient was without new complaint, vital signs were normal and pain management was with oral medications. The patient remained clinically stable and was discharged from the inpatient setting on day #4 with planned short term follow up. The drain was kept in place at the time of discharge. The health plan denial letter states that there is no documentation of unstable vital signs or fever, signs of infection, stone or blockage of the bile duct, or jaundice. The denial of inpatient admission was based on Milliman Care Guidelines (MCG) Gallbladder or Bile Duct Inflammation or Stone. This letter states that the health plan approved the hospital stay at an observation level of care (rather than acute inpatient level of care).

The inpatient care was medically necessary and appropriate for this patient.

This patient presented to the hospital with acute cholelithiasis/cholecystitis. Presurgical imaging and lab data supported the diagnosis of acute cholecystitis and the operative findings confirmed that there was acute cholecystitis such that a 
surgical drain was placed at the time of surgery. The patient required pre-and post-surgical antibiotics. The records support timely, expeditious, and medically necessary care. Per generally accepted criteria and the submitted Milliman Care Guidelines (MCG), inpatient care is needed when there is:
- Right upper quadrant pain, mass or tenderness AND fever, C-reactive protein greater than 10 or white blood cell count greater than 10 thousand
- Acute cholecystitis 
- Evidence of bile duct disease
- Common bile duct obstruction
- Vomiting that is severe
- Dehydration
- Hemodynamic instability
- Severe pain 
- Intestinal obstruction
- Bacteremia
- Percutaneous or open drainage procedures
- Other condition that requires inpatient admission.
In this case, there is documentation of severity of disease (right upper abdominal pain and tenderness, white blood cell count greater than 10 thousand), an anticipated length of stay greater than 48-hours, and failure to achieve discharge criteria that required inpatient admission. There is clinical and pathological confirmation of the diagnosis of acute cholecystitis. Acute inpatient care was medically necessary for this patient as the care and treatment provided was most appropriately rendered in the inpatient setting during this time.