Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal-Gallbladder problem-choleycystitis.
Treatment: Inpatient hospital stay.
The health plan denied the inpatient hospital stay as not medically necessary. 
The reviewer has upheld in whole the health plan's determination in whole.

The patient presented to the emergency department (ED) with epigastric abdominal pain. At the time of presentation, the patient was without fever and the blood pressure was elevated at 180/110 millimeters of mercury (mmHg). She had a nontender abdomen per the examination. The white blood cell (WBC) count was elevated at 15 thousand (K). The complete metabolic panel was normal. A computed tomography (CT) scan showed findings of cholecystitis. She was initially treated with intravenous (IV) fluid and IV antibiotics. 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 fluid, IV analgesia, and antiemetics. The immediate post-surgical recovery was uncomplicated. Pain was controlled. The diet was advanced. The patient remained clinically stable and was discharged .

There is no clinical documentation to support the need for inpatient admission or why this patient could not have safely and appropriately been treated at a lower level of care. This patient presented to the hospital with cholelithiasis/cholecystitis. The submitted records document that this patient was clinically and hemodynamically stable at the time of presentation. The serum chemistries were normal at the time of presentation. The indication for cholecystectomy was established the day of admission. The patient underwent an uncomplicated laparoscopic cholecystectomy procedure 3 days later. There were no peri-operative complications or other clinical issues that mandated an inpatient designation. 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. She remained stable and was discharged from the hospital following surgery. A lower level of care would have permitted for the pre-surgical assessment, the surgical procedure, and perioperative IV fluid, IV antibiotics, IV antiemetics, and post-surgical monitoring. The patient was clinically stable following surgery as supported by the corresponding medical records.
Inpatient admission may be 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. An inpatient level of care was not required for the care and treatment of this patient. The medical record supports that the patient could have been reasonably and appropriately treated with an observation level of care.