Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal/Cholecystitis/Inflammation of the Gallbladder/Acute Cholecystitis
Treatment: Inpatient Hospital Admission
The health plan denied the requested inpatient hospital admission as not medically necessary. The health plan's determination is overturned.

This female patient with a medical history significant for Churg-Strauss syndrome presented to the emergency department with diffuse body aches, numbness, and serial generalized pain. The patient described the sensation of paresthesias and stated that her Churg-Strauss syndrome had been controlled for many years, but within the last year has had several flare-ups.
The patient denied fever, chest pain, shortness of breath, vomiting, or any other symptoms. The patient was admitted two months before the current admission for similar reasons.
In the emergency room (ER), she underwent a computed tomography (CT) scan of the abdomen and pelvis, which was unremarkable. On the physical exam, the patient was afebrile. Her pulse rate was 104 beats per minute (bpm), with a blood pressure 154/104 millimeters of mercury (mmHg), a respiratory rate of 24 breaths/min, and an oxygen saturation of 94%.
She was awake, alert, and in no acute distress. The abdomen was soft and non-tender to palpation. The rest of the physical exam was unremarkable.
The patient was admitted to the hospital with Churg-Strauss syndrome, abdominal pain/musculoskeletal pain. The patient was seen by the surgical service. They recommended a gastroenterology evaluation, as well as a hepatobiliary iminodiacetic acid (HIDA) scan. The HIDA was performed and demonstrated acute cholecystitis. The patient was started on intravenous antibiotics including Ciprofloxacin, and Metronidazole. She received treatment with intravenous fluids.
The patient was recommended to have surgery due to persistent acute cholecystitis. Initially, the patient stated that she wanted to try treatment with intravenous antibiotics first. Subsequently, the patient was transferred to another facility for a cholecystectomy, due to the need for a higher level of care in this complex case.
At issue is the medical necessity for the inpatient hospital admission.

I overturn, in whole, the health plan's determination.

Acute inpatient level of care was completely justified in this clinical case, due to the complexity of the patient's condition, and the complexity of the decision-making. The timeframe of the care provided significantly exceeded the acceptable timeframe for observation care.
This was a highly complex clinical situation. This patient was previously diagnosed with Eosinophilic Granulomatosis with Polyangiitis (EGPA), known as Churg-Strauss Syndrome. This is a condition that is associated with respiratory, neurologic, cutaneous, musculoskeletal, cardiac, gastrointestinal, and renal manifestations.
In this clinical case, the patient had musculoskeletal manifestations as well as gastrointestinal and possibly neurologic symptoms. The treatment of EGPA mainly consists of systemic corticosteroids. Therefore, in this acute situation, the treatment with intravenous Solu-Medrol was completely appropriate, while monitoring the clinical response.
Since the clinical response was not optimal, the patient underwent a HIDA scan, which was suggestive of acute cholecystitis and prompted the initiation of treatment with intravenous antibiotics in the patient who's been treated with corticosteroids. The delay in the diagnosis of acute cholecystitis was due to unremarkable results of the CT scan of the abdomen and pelvis, which was done at the time of admission.
For that reason, I think this was a very complex situation. The severity of the patient's symptoms, the complexity of the decision-making, and the timeframe of the hospitalization was most consistent with the acute inpatient level of care.