Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld.

The patient is a male who presented to the emergency department (ED) with new onset right upper abdominal pain.  At the time of presentation, the patient was without fever and vital signs were normal.  He was tender in the right upper quadrant.  The white blood cell (WBC) count was normal.  The complete metabolic panel identified normal liver enzymes and bilirubin.  Abdominal ultrasound showed gallstones within the gallbladder without gallbladder wall thickening.  

The patient was evaluated with surgery consultation.  The patient underwent laparoscopic cholecystectomy.  The operation was performed without complication.  The diet was advanced and pain was controlled.  The patient remained clinically stable and was discharged from the inpatient setting with planned short term follow up.

No, the proposed inpatient hospital admission was not medically necessary.

An inpatient level of care was not medically necessary in this case.  This patient is a male who presented to the hospital with abdominal pain.  He was determined to have cholelithiasis/cholecystitis/biliary colic.  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, conversion to open surgery, care for comorbidities, or any other condition requiring inpatient admission.  The indication for cholecystectomy was established.  The patient was admitted to the hospital.  He underwent surgery to remove the gallbladder.  The patient responded favorably to treatment and was stable for discharge from the hospital with planned follow up.  

Acute inpatient care was not medically necessary for this patient as the care and treatment provided could have been rendered with a lower level of care.  A lower level of care would have provided for emergency department assessment, surgical assessment and monitoring, laparoscopic cholecystectomy as performed, provision of intravenous antibiotics and fluid, and overnight care.

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.

The health plan acted reasonably.  Inpatient level of care was not medically necessary.  A lower level of care would have permitted for the surgical assessment, the surgical procedure and perioperative intravenous fluid, intravenous antibiotics, intravenous antiemetics, and overnight monitoring.  The submitted records document that this patient was clinically and hemodynamically stable at the time of presentation.  The patient was clinically stable throughout the period of monitoring as supported by the corresponding medical records.  

Inpatient care may be indicated when there is right upper quadrant pain, AND systemic signs of inflammation (fever, C-reactive protein greater than ten, white blood cell count greater than ten thousand).  Inpatient admission may also 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, the white blood cell count and liver enzymes were normal, the patient was clinically stable, the indication for cholecystectomy was established and the patient underwent an uncomplicated cholecystectomy procedure.  The post-surgical course was uneventful and the patient was able to be discharged from the hospital on the first post surgical day.  None of these indications for an inpatient designation existed to justify an inpatient level of care.