Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Epigastric Pain
Treatment: Inpatient Hospital Stay
The insurer denied Inpatient Hospital Stay.
The determination is upheld.

This is a female patient with a medical history of gastroesophageal reflux disease (GERD) and cholecystectomy.  She presented to the emergency department with a few days of epigastric pain with eating, that was improved with Pepcid.  A computed tomography scan of the abdomen and pelvis showed no acute abdominal or pelvic pathology, hepatomegaly, prominence of the common bile duct and intrahepatic dilation which may be due to calcific density subcentimeter subcutaneous nodule, renal fold thickening of the stomach which may be due to gastritis versus neoplastic process, findings suggestive of cystitis, and some inflammatory changes in the gallbladder fossa which may be postoperative.  An ultrasound of the right upper quadrant showed normal right upper quadrant status postcholecystectomy.  She was treated with intravenous fluids.  She was made nil per os. A gastroenterology consultation noted upper abdominal pain and elevated liver enzymes, and recommended nil per os, intravenous fluids, follow blood count and liver enzymes, and endoscopic ultrasound to evaluate for common bile duct stones with endoscopic retrograde cholangiopancreatography if indicated.  An endoscopic ultrasound showed one stone in the common bile duct, dilation of the common bile duct to 12 millimeters (mm), and no pathology in the pancreas or the left lobe of the liver.  Endoscopic retrograde cholangiopancreatography was technically difficult due to challenging cannulation and abnormal anatomy, and revealed moderately dilated entire main bile duct and choledocholithiasis; biliary sphincterotomy, stone extraction with balloon, pancreatic sphincterotomy, and pancreatic duct stent placement were performed; the recommendation was nil per os, intravenous fluids, rectal indomethacin suppository, follow liver enzymes, and abdominal x-ray in 1 to 2 weeks to confirm dislodgment of pancreatic duct stent. At issue is the medical necessity for the inpatient level of care. 
The inpatient level of care is not medically necessary. The patient presented with epigastric pain and elevated liver enzymes, and was found to have choledocholithiasis on endoscopic ultrasound. Endoscopic retrograde cholangiopancreatography was performed, and choledocholithiasis was addressed (biliary sphincterotomy was appropriately performed); there were no documented complications such as post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis or bleeding. She had subsequent improvement in her symptoms and a decrease in liver enzymes. However, there was no persistent hemodynamic instability, cholangitis, or other complications such as gallstone pancreatitis, hepatic or abdominal abscess, peritonitis, or sepsis, which would require a higher level of care [1-4]. Given the lack of complications, and given improvement with therapy, the care provided, including monitoring, labs, imaging, Gastroenterology consultation, endoscopic ultrasound, and ERCP could have been performed in sequence after presentation, without the need for the inpatient level of care.