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 female who presented with abdominal pain of three-days duration.  Comorbid health conditions included a history of breast cancer.  At the time of presentation the patient was without fever and vital signs showed a normal heart rate and blood pressure of 141/87 millimeters of mercury (mmHg).  She was tender in the right upper abdomen.  The white blood cell (WBC) count was 4.8 thousand (K).  The complete metabolic panel  identified elevated serum transaminases with normal bilirubin.  Ultrasound showed gallstones, a thick gallbladder wall and an eight-millimeter common bile duct (CBD).  She was admitted to the hospital.  She was initially treated with intravenous (IV) fluid, pain medications and antiemetics.  She was treated with laparoscopic (robotic) cholecystectomy. The operative dictation and the anesthetic record describe an uncomplicated cholecystectomy procedure.  

The patient was treated with post-surgical monitoring, intravenous fluid, intravenous analgesia, and antiemetics.  The immediate post-surgical recovery was uncomplicated. Following surgery, the patient had stable vital signs.  The patient did complain of abdominal discomfort.  The diet was advanced.  The patient remained clinically stable and was discharged from the inpatient setting.

The health plan letter references MCG (Milliman Care Guidelines) 24th ed. Gallbladder or Bile Duct Inflammation or Stone and Cholecystectomy by Laparoscopy.  The health plan letter states that hospital admission was not medically necessary.

No, the proposed treatment was not medically necessary.
An inpatient level of care was not medically necessary in this case.  This patient is a female who presented to the hospital emergency department with cholelithiasis/cholecystitis.  There is no documentation of hemodynamic, pulmonary, neurological, or metabolic reason for an acute inpatient level of care at the time of presentation.  Additionally, there is no documentation of failure to achieve discharge criteria, conversion to open surgery, care for comorbidities, procedural complications, or any other condition requiring inpatient admission.  

Acute inpatient care was not medically necessary for this patient as the care and treatment provided could have been rendered in the observational setting.  An observational level of care would have provided for emergency department assessment, surgical assessment, imaging with ultrasound, perioperative care and monitoring, provision of intravenous fluid and medication, and overnight care.  The patient was admitted to the hospital and was stable for discharge from the hospital on day three.  The care provided during this time could have reasonably been rendered with an observation level of care.

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
There is no compelling reason why this patient could not have safely and appropriately been treated at the observation level of care.  Based on the submitted clinical documentation, an inpatient level of care was not medically necessary.  This patient was admitted to the hospital with the diagnosis of cholelithiasis/cholecystitis. Her pre-surgical assessment and the indication for surgery was established.  The patient underwent an uncomplicated laparoscopic cholecystectomy procedure the following day.  There were no peri-operative complications or other clinical issues.  She remained stable and was discharged from the hospital on day three.  

Inpatient level of care was not medically necessary.  An observation level of care would have permitted for the pre-surgical assessment, the surgical procedure and perioperative intravenous fluid, intravenous antibiotics, intravenous antiemetics, and post-surgical monitoring.  The patient was clinically stable following surgery as supported by the corresponding medical records.

The submitted records document that this patient was clinically and hemodynamically stable at the time of presentation.  The white blood cell (WBC) count was normal at 4.8 thousand (K).  Serum chemistries identified elevated serum transaminases and normal bilirubin.  Surgery was performed the following day and the perioperative period was uncomplicated.  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.  An observational level of care would have satisfied the clinical needs of this patient.

In regards to the referenced MCG (Milliman Care Guidelines) Gallbladder or Bile Duct Inflammation, Inpatient and Surgical Care 24th  edition, these MCG (Milliman Care Guidelines) state that inpatient care is indicated when there is right upper quadrant pain, and systemic signs of inflammation (fever, C-reactive protein greater than ten, white blood cell [WBC] count greater than ten thousand).  Inpatient admission is also 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.