Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal/Gallbladder Problem/Infected Gallbladder
Treatment: Inpatient Hospital
The health plan denied the requested inpatient stay as not medically necessary. 
The health plan's determination is upheld.

The patient is a woman who presented to the emergency department (ED) with  recurrent right sided abdominal pain. At the time of presentation, the patient was without fever and the heart rate was 74/minute. She had a tender abdomen per the examination. The white blood cell (WBC) count was normal at 6.3 K. The complete metabolic panel was normal. An ultrasound showed findings of gallstones. She was initially treated with intravenous (IV) fluid and IV antibiotics. She was admitted to the hospital and started on IV antibiotics. The patient was reported to have improved pain and was started on a liquid diet. A routine preoperative COVID test returned positive and plans for a cholecystectomy during this admission were postponed. The patient remained clinically stable and was discharged from the inpatient setting  with instructions for outpatient follow up.
At issue is the medical necessity for the inpatient stay.

The health plan's determination is upheld, in whole.

No. An inpatient level of care was not medically necessary in this case. This patient is a woman who presented to the hospital with abdominal pain. The records and her diagnostic work up supported the diagnosis of cholelithiasis/biliary colic, and this diagnosis was established. When a COVID test revealed a positive result, plans for surgery were postponed per protocol. 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, or any other condition requiring an inpatient admission. Acute inpatient care was not medically necessary for this patient, as the care and treatment provided could have been rendered with an alternative level of care. An alternative level of care would have provided for ED assessment, surgical consultation, monitoring, provision of IV antibiotics and fluid, and overnight care. The records in this case support the medical necessity of a cholecystectomy, though this procedure was not performed during this hospital presentation.
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 an alternative level of care. The submitted records document that this patient was clinically and hemodynamically stable at the time of presentation. The serum chemistries were normal at the time of presentation. Based on the submitted clinical documentation, an inpatient level of care was not medically necessary. The patient was treated non-operatively during this admission with planned outpatient follow up due to a positive COVID test. There were no hospital complications or other clinical issues that mandated an inpatient designation. She remained stable and was discharged from the hospital.
Inpatient level of care was not medically necessary. An alternative level of care would have permitted for the ED and surgical assessment, imaging, lab data, 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 liquid 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.