Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Abdominal pain.
Treatment:  Inpatient admission.

The insurer denied coverage for an inpatient admission.  The denial is overturned.

This is the case of a patient with a history of hypothyroidism and acute cholecystitis s/p (status post) lap (laparoscopic) cholecystectomy, who presented to the emergency department (ED) with complaints of vomiting and abdominal pain. As per the ED nurse, the patient was afebrile. As per the ED provider note, the patient presented to the ED for nausea, vomiting and continuous diffuse abdominal pain radiating to the back and left shoulder. There was minimal improvement with Tylenol. She had no concerns after the lap cholecystectomy but started having pain the night prior and similar to the pain prior to the cholecystectomy but slightly different. She denied fever, chest pain. On exam her abdomen was soft, non-distended, diffusely tender, worse in the epigastric region with guarding but without rebound. The differential was post op complication versus infection versus choledocholithiasis. The plan was labs, including LFT's (liver function tests), lipase, RUQ (right upper quadrant) sonogram and computed tomography (CT) of the abdomen. Surgery was made aware.

Based upon the records the inpatient admission was justified, as this patient could not have been managed as noted by the insurer in an ambulatory/observation setting. She presented with an elevated WBC (white blood cell count) of 15K (thousand) as well as markedly elevated liver function tests and was s/p lap cholecystectomy almost 2 weeks earlier. It was not clear what the cause for the WBC and the elevated liver function tests were. It had to be assumed that the patient had an infection and did have a CBD (common bile duct) of 8mm (millimeters) which could have signified acute cholangitis despite not having a fever. Thus, the prudent course of action was to admit and to begin antibiotics and monitor.
 
In addition according to MCG (Milliman Care Guidelines) Inpatient and Surgical Care 26th Edition Abdominal Pain, Undiagnosed ORG: M-05 (ISC), admission may be indicated for 1 or more of the following: 1) Hemodynamic instability; 2) Severe pain requiring acute inpatient management; 3) Peritoneal signs; 4) Identification of etiology or finding that requires inpatient care (e.g., aortic dissection, bowel perforation, bowel ischemia, visceral organ torsion; intestinal obstruction); 5) Evaluation requires the patient to not eat or drink for an extended period (e.g., more than 24 hours); Inability to maintain oral hydration (e.g. needs IV fluid support) that persists after emergency department and observation care treatment; or 6) Suspected toxic megacolon; bacteremia; and a procedure that cannot be performed on an ambulatory basis. Thus, in this case the patient warranted an inpatient admission, as it was not clear what the initial cause of the elevated WBC and markedly abnormal liver enzymes were due to and if there was a significant intra-abdominal problem. Finally, the reviewer is knowledgeable in this condition and the recommended health care services provided through actual clinical experience for this condition and therefore feels that the inpatient admission was justified at the inpatient admission level, as the patient could not have been managed initially in an ambulatory/observation setting. The reviewer does believe that based upon these findings the health care plan did not act reasonably and with sound medical judgment. The criteria the reviewer has utilized included the reviewer's own personal experience as to what constituted good acceptable standard of care, as well as the MCG guidelines, as noted. 

The insurer's denial of coverage for the inpatient hospital is overturned. Medical Necessity is substantiated.