Appeal type: Medical necessity
Decision: Upheld

Dx: Digestive System/Gastrointestinal
Tx: Inpatient Hospital
Denied: Inpatient stay
Denial: UPHELD in whole

The patient is a female with medical history of gastroesophageal reflux disease (GERD) and insomnia. She had undergone a laparoscopic cholecystectomy and had been discharged the day prior. She presented with intractable abdominal pain, nausea, and vomiting since early morning. She described the pain as non-radiating and generalized but focused at the surgical sites. Physical examination was notable for abdominal tenderness. Labs were notable for low potassium of 3.2 milliequivalents per liter (mEq/L), elevated aspartate aminotransferase of 390 U/L, elevated alanine aminotransferase of 531 U/L, elevated total bilirubin of 3.2 milligrams per deciliter (mg/dL), and elevated direct bilirubin of 2.1 mg/dL. Chest x-ray showed no acute abnormalities. Computed tomography scan of the abdomen and pelvis showed gas in the subcutaneous tissues and in the abdominal cavity, and a trace amount of fluid in the pelvis. Ultrasound of the abdomen showed dilated common bile duct at 8 millimeter (mm) and prior cholecystectomy. General Surgery consultation noted suspected choledocholithiasis and recommended a magnetic resonance cholangiopancreatography, use of ceftriaxone and metronidazole, nothing by mouth (NPO) status, and repeat metabolic profile with direct bilirubin. She was made NPO status and treated with intravenous lactated ringers fluid, ondansetron, pantoprazole, morphine, ketorolac, ceftriaxone, ciprofloxacin, and metronidazole. Magnetic resonance cholangiopancreatography showed common bile duct dilation to 11 mm with smooth tapering, no obstructive filling defect, and mild dilation of the intrahepatic ducts, predominantly in the left hepatic lobe. The next day, she was tolerating a regular diet well. Labs showed low hemoglobin of 11.1 grams per deciliter (g/dL), normalized potassium, and decreased alanine aminotransferase of 425 U/L and markedly decreased aspartate aminotransferase of 164 U/L; bilirubin was normalized. She was discharged with a plan for General Surgery follow-up. At issue is the medical necessity for the inpatient stay.

The health plan's determination is upheld in whole. 

The inpatient level of care is not supported as medically necessary. The patient presented with abdominal pain after cholecystectomy, resulting in concern for choledocholithiasis, and there was the possibility of postoperative complications. [1,2] However, no choledocholithiasis was found, and no postoperative complication such as ileus or operative complication such as bowel perforation or bile leak was identified; there was no hemodynamic instability or other complications such as ascending cholangitis, hepatic abscess, abdominal abscess, active gastrointestinal bleeding, peritonitis, fistula, or sepsis, which might require the inpatient stay. [1-5] Transaminases improved, and bilirubin normalized by the day after presentation, and she tolerated a regular diet. The care provided, including monitoring, labs, Surgery consultation, empiric antibiotic therapy, and magnetic resonance cholangiopancreatography, could have been performed without the inpatient level of care. [1-5] For these reasons, the inpatient stay is not supported.