Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cholelithiasis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

This is the case of a patient who presented to the emergency department (ED) from home complaining of abdominal pain. The patient was afebrile with stable vital signs. As per the ED provider note the patient has a history of gallstones. The patient has abdominal pain and denied fever or nausea. Exam revealed the patient's abdomen to be tender in the right upper quadrant (RUQ) but soft without guarding. Of note the patient did refuse surgery previously for childcare reasons. Surgery was now consulted, and surgery recommended admission.

The history and physical noted that the patient had a history of cholelithiasis and gallbladder adenomyomatosis. The patient returned after recent discharge at which time the patient also complained of abdominal pain. The patient had known gallbladder sludge and cholelithiasis. The patient had been admitted twice before and had extensive workup including Magnetic Resonance Cholangiopancreatography (MRCP) and Hepatobiliary Iminodiacetic Acid (HIDA) scan which were negative for acute cholecystitis. The patient elected to pursue surgery in the outpatient setting however the patient found out the surgeon did not take their insurance. The patient returned with RUQ pain however due to lack of operating room (OR) availability the patient was scheduled for a later date. However, the patient elected to leave as they needed to provide childcare. The patient tolerated dinner at that time and was discharged to home. The patient now returned today after eating rice and chicken at home and now was in distress due to pain. The patient denied nausea or vomiting. White blood cell count (WBC) was 7.06. Liver function tests (LFT's) were normal. The patient was admitted with plan of surgery.  

The insurer has denied coverage for inpatient hospital admission. In their Final Adverse Determination letter they stated that they are not changing their denial. The patient came to the ED with abdominal pain and was admitted for lap cholecystectomy. To approve this service the following must be met: the medical information sent to the insurer did not meet their clinical criteria for an inpatient admission which are based in part on Milliman Care Guidelines (MCG). 

The hospital is appealing and noted in an appeal letter stating that this admission was clinically and medically necessary and supported by documentation in the medical chart and supported by MCG 26th edition Ambulatory surgery exception criteria GRG: CG-AEC and  General admission criteria GRG: (CG-GAC) for acute inpatient status.  

Based upon these guidelines this patient should have been observed rather than placed in an acute admission as the patient did not have any indication as noted above for inpatient stay or prolonged stay. 

MCG General Recovery Care 27th Edition Ambulatory Surgery Exception Criteria GRG:CG-AEC (ISC GRG) notes that potentially ambulatory procedure or surgery warrants inpatient care due to 1 or more of the following: Inpatient care needed for clinically significant preoperative disease or condition; Complex surgical approach or situation anticipated; Procedure is not low risk and patient at high anesthetic risk; Presence of drug-related risk; Inadequate outpatient care situation; Postoperative event, condition, or finding that warrants inpatient stay. Given the above the patient did not warrant inpatient status as the patient should have been managed in an ambulatory setting/observation setting. 

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 inpatient hospital admission is not substantiated.