Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cholelithiasis/cholecystitis.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay. 
The determination is upheld.

This is a patient who presented to the emergency department (ED) with right sided abdominal pain, nausea and vomiting of 1-day duration. She had a history of nephrolithiasis. At the time of presentation, the patient was without a fever and the heart rate was 56 beats/minute. She had a tender abdomen. The white blood cell count (WBC) count was normal at 7.0 thousand (K). The complete metabolic panel showed normal bilirubin and transaminases. An abdominal ultrasound showed gallstones and a sonographic Murphy's sign. The patient underwent a laparoscopic cholecystectomy. The operative report describes a cholecystectomy procedure that was completed without complication. The post-surgical course was also uncomplicated. The diet was advanced and the patient was considered stable for discharge home.  At issue is the medical necessity of an inpatient stay.

An inpatient level of care was not medically necessary in this case. This patient presented to the hospital with abdominal pain. The records and the diagnostic work up supported the diagnosis of cholelithiasis/cholecystitis and this diagnosis was established. 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, care for comorbidities, procedural complications, or any other condition requiring inpatient admission.

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 was admitted to the hospital with the diagnosis of abdominal pain/cholelithiasis/cholecystitis. The patient was treated with a laparoscopic cholecystectomy. There were no hospital complications or other clinical issues that mandated an inpatient designation. She remained stable and was discharged from the hospital on the first post-surgical day.

Inpatient level of care was not medically necessary. A lower level of care would have permitted for the emergency department (ED) and surgical assessment, imaging, lab data, intravenous (IV) fluid, IV antibiotics, IV antiemetics, and overnight monitoring. The patient remained clinically stable as supported by the corresponding medical records. She was tolerating a diet and oral analgesia. Inpatient stay may be needed for failure to achieve discharge status criteria, conversion to open surgery, systemic infection, care for active comorbidities, complications of procedure. In this case, none of these conditions existed to warrant an inpatient level of care.

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.