Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal and back pain
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient is an adult previously healthy female who presented to the emergency department with complaints of back and 
abdominal pain. Her past medical history is notable for no chronic medical health conditions. The patient's vital signs were normal at the time of presentation. The patient was evaluated with computed tomography (CT) scan and abdominal ultrasound that identified gallstones and a thickened gallbladder wall/pericholecystic fluid. There was also a right ovarian cyst.
The patient was admitted to the hospital. The surgical history and physical is dated the next day and document a normal white blood cell count of 8.7 thousand (K) with normal liver enzymes and bilirubin. Laparoscopic cholecystectomy was recommended and planned. The patient was started on intravenous antibiotics.
Surgery was performed on day #3. The operative notes describe laparoscopic cholecystectomy and intraoperative cholangiogram that were performed without complication. The pathology report describes gallstones and chronic cholecystitis. The day following surgery, the patient's diet was advanced, and her pain was controlled with oral medications. The patient's vital signs were normal. The patient remained clinically stable and was discharged from the inpatient setting.
The material submitted for review includes the health plan denial letter. This letter states that inpatient admission to the hospital was not needed in this case following gallbladder surgery and that the care provided could have been rendered with a lower level of care. This letter references InterQual criteria.

The requested health service was not medically necessary.

Inpatient care was not medically necessary in this case. The care provided could have been rendered with a lower level of care. A lower level of care would have provided for initial assessment, perioperative care and monitoring, provision of intravenous fluid, surgical consultation, and performance of cholecystectomy. The indication for cholecystectomy was established on admission. There were no peri-procedure complications or other clinical issues. Inpatient care may be needed when there is: "Acute cholangitis with systemic signs of sepsis and evidence of common bile duct disease with bilirubin > than 2 mg/dl or AST/ALT 1.5 times upper limit of normal, or imaging showing biliary dilatation or evidence of etiology. Acute cholecystitis 
(RUQ pain or tenderness, systemic signs of inflammation, Cholecystectomy not anticipated due to high surgical risk or plan for interval cholecystectomy). Also, criteria for inpatient admission 
may include: Failure to achieve discharge criteria; Conversion to open surgery; Severe post-operative infection; Care for active comorbidities; Complications of procedure; Gallstone ileus."
In this case, the patient presented with symptoms related to cholecystitis. The evaluation and the indication for cholecystectomy was established on admission. The cholecystectomy procedure was performed on day #3 without complication, and the patient was stable for discharge from the hospital on the first post-surgical day. The patient responded promptly and without complication to the prescribed therapy (cholecystectomy). The above noted conditions did not exist to warrant an inpatient level of care. The patient's presenting condition at the hospital and clinical course did not justify an inpatient level of care. The care provided could have appropriately been rendered with a lower level of care. Therefore, the requested health service was not medically necessary.