Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Biliary Colic

Treatment: inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld.

This is the case of a patient with a history of gastritis who presented to the emergency room (ER) with complaints of epigastric and right upper quadrant (RUQ) pain that worsened with food intake.  The patient denied nausea and vomiting and he had minimal relief with pain medication. His vital signs were significant for a blood pressure (BP) of 165/93 but otherwise within normal limits. The patient presented to the ER and was admitted. The emergency department (ED) provider noted that the patient was recently hospitalized for similar concerns one week ago. He was given medications and discharged. He stated he has been having mid epigastric pain described as burning. He denied fevers, chills, nausea, vomiting. On exam, he was afebrile. His abdomen was soft with abdominal tenderness in the epigastric region. The concern was for gastritis but could not exclude aortic pathology given the patient's hypertension and mid epigastric pain. A bedside sonogram of the abdomen was indeterminate. Computed tomography (CT) of the abdomen revealed imaging of the gallbladder was degraded by motion artifact.  No calcified stone or ductal dilation was noted. The plan was consult general surgery for biliary colic. White blood count (WBC) was normal (5.9). Liver function test (LFT) mildly elevated (AST [Aspartate transaminase] 142) with total bilirubin of 2.1 and direct bilirubin of 1.1. The plan was to admit to surgery and plan for right upper quadrant (RUQ) sonogram.

The patient was deemed medically stable for discharge with outpatient instructions for follow up with surgery.

Based upon the records the admission was not justified as this patient could have been managed in an ambulatory/observation setting as he did not have elevated WBC, fever, or a confirmatory test to show that he had acute cholecystitis. In fact, the surgical consult assessment was for biliary colic. He did not meet criteria for an acute admission for acute cholecystitis so he could have been managed in an observation/ambulatory setting as noted by the insurer. According to the guidelines of MCG (Milliman Care Guidelines) Health Inpatient and Surgical care- 25th edition Gall bladder or bile duct inflammation or stone M-555 the goal length of stay is ambulatory or 2 days and assumes optimal recovery, decision making, and care. Patients may be discharged to a lower level of care (either later than or sooner than the goal) when it is appropriate for their clinical status and care needs. 

Furthermore, according to MCG Inpatient and Surgical Care 25th Edition cholecystectomy by laparoscopy the operative status criteria is ambulatory. Thus, this patient could have been managed without an inpatient acute admission for this procedure.

The health care plan did act reasonably and with sound medical judgment and in the best interest of this patient as the patient did not meet criteria for admission but rather ambulatory/observation status.   

Based on the above, the medical necessity inpatient admission is not substantiated. The insurer's denial is upheld.