Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Biliary pancreatitis. 
Treatment: Inpatient admission. 
The insurer denied coverage for inpatient admission. 
The denial is upheld. 

This is a patient who presented for elective admission. As per the History and Physical the patient was admitted in previously for severe biliary pancreatitis with respiratory distress, hypothermia and hypotension. She recovered well though she had a prolonged hospital course including development of loculated peri-pancreatic collection in the anterior abdomen requiring drainage x 2 by interventional radiology (IR). She also underwent Esophagogastroduodenoscopy (EGD) with common bile duct (CBD) stent and sphincterotomy as well as attempted endoscopic cystogastrostomy. Her nutrition was improved, and she has been off antibiotics and was discharged with 2 IR drains. Outpatient follow-up revealed appropriate drainage as well as decrease in size of the right upper quadrant (RUQ) peri-pancreatic collection. One drain was removed, and the patient was now here for follow-up several weeks since initial admission for laparoscopic cholecystectomy and drainage of RUQ collection. She was afebrile with the abdomen being soft non-distended, non-tender with drain in place with white/grey debris and thick fluid drainage. Computed tomography (CT) revealed no size of the collection.
She underwent laparoscopic cholecystectomy and drainage of peri-pancreatic collection with placement of Jackson - Pratt (JP) drain. Findings at the time of surgery included significant adhesion of the stomach, transverse colon, and small bowel to large phlegmonous abscess/collection in the RUQ attached to the anterior abdominal wall around the IR drain sites. Procedure went well without complications and the surgery was uneventful. 

White Blood Cells (WBC) on admission day 2 were 11.3. 

The patient continued to do well and was discharged. As per the discharge summary the patient did well intraoperatively but was admitted overnight for observation and morning labs. As per the physician discharge summary the patient was discharged. 

The treating physician's plan and treatment course consisted of making the patient nothing by mouth (NPO), intravenous (IV) fluids, and undergoing lap cholecystectomy with drainage of multiple intraabdominal fluid collections and drain placements. She tolerated the procedure well and was transferred from the post anesthesia care unit (PACU) to the floor without complication. The diet was advanced, and she was cleared for discharge to home. She met Milliman Care Guidelines (MCG) criteria for a safe discharge. 

Based upon the records, acute inpatient admission from was not justified as this patient could have been managed in an ambulatory/observation setting as she had an uneventful laparoscopic cholecystectomy. The operation was a scheduled elective operation at this time. The patient was kept overnight as per the discharge summary for observation. Therefore, there was no indication to keep the patient in an inpatient mode but rather observation. She did not have a significantly elevated WBC and she did not have a fever. She did not have abnormal liver function tests. She presented now for an elective lap cholecystectomy and drainage of collection. She was admitted as per the note for observation. Therefore, observation would have been warranted and not an acute inpatient admission. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient admission is not substantiated.