Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Right upper quadrant (RUQ) abdominal pain

Treatment: inpatient hospital admission

The insurer denied coverage for inpatient hospital admission. The denial is reversed. 

This patient is a female with past medical history significant for recent laparoscopic cholecystectomy.  The patient presented to the hospital Emergency Room (ER) with nausea, vomiting, and 10 out of 10 right upper quadrant (RUQ) abdominal pain. The patient presented being status post laparoscopic cholecystectomy several days. The patient left the hospital the day before this ED arrival, and did not get her medications filled at the pharmacy. The patient reported having 5 episodes of vomiting at home and took Motrin for pain with no relief. The patient also reported that the color of her JP drain output changed, and that there was increased amount of drainage. The patient was not able to keep any food down. On physical exam, the patient was afebrile with stable vital signs. The patient's abdomen was soft, non-tender with serosanguinous drainage from the JP. The patient's labs revealed an alkaline phosphatase of 387, AST 485, and ALT 477.

The patient's computed tomography (CT) scan of the abdomen was done and revealed a small amount of fluid soft tissue density in the gall bladder fossa compatible with postoperative changes with mild intrahepatic biliary ductal dilatation. The common bile duct measured up to 8 mm, and no stones were identified in the common bile duct. Gastroenterology and Surgery saw the patient and were suspicious for a bile leak.  The plan was to proceed with an endoscopic retrograde cholangiopancreatography (ERCP). Multiple stones were removed from the common bile duct, and after the stone extractions, a 10 French pigtail stent was placed into the common bile duct; drainage was then brisk through the stent. The patient was discharged home with antibiotics.
According to MCG guidelines for Gall bladder or bile duct inflammation or stone (ORG: M-555 (ISC)), the goal length of stay is ambulatory or 2 days and assumes optimal recovery, decision making, and care. Patients may be discharged to a lower level of care (either later than or sooner than the goal) when it is appropriate for their clinical status and care needs. The clinical indications for admission to inpatient care may include patients with 1 or more reasons.

In this case, the patient did have the clinical signs and symptoms requiring inpatient admission. The patient had evidence of common bile duct disease indicated by 1 or more of the following: Liver function test (alkaline phosphatase (ALP), r-glutamyl transferase (GGT), aspartate aminotransferase (AST), or alanine aminotransferase (ALT)) greater than 1.5 times the upper limit of normal. In addition, the patient had evidence of biliary dilatation on the computed tomography (CT) scan of the abdomen, and the HIDA scan that showed drainage delay through the JP drain that implied leakage and/or obstruction. The patient clinical condition needed an urgent ERCP procedure with sphincterotomy, papillotomy and stent placement. The patient needed to be kept nothing-by-mouth (NPO) status, and needed an intervention as it turned out that the patient had multiple filling defects in the common bile duct, as well as drainage through the JP drain which would not have resolved without intervention. Thus, the patient met the clinical criteria for admission and could not have been treated with observation level of care. 

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the inpatient hospital admission is reversed. The medical necessity is substantiated.