Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System / Gastrointestinal. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is upheld in whole. 

The patient is a male with multiple medical problems including advanced coronary disease, atrial fibrillation on Eliquis, automatic implantable cardioverter defibrillator (AICD), who presented to the hospital with complaints of diarrhea and right upper quadrant pain. The symptoms started three days before presentation, with non-bloody watery diarrhea, decreased appetite, and concurrent right upper quadrant pain.
On evaluation, vital signs were relatively stable, with normal temperature, blood pressure of 137/75, and a pulse rate of 88. On exam, the patient was comfortable appearing, with regular rate and rhythm and soft abdomen, non-distended, with positive Murphy sign.

Laboratory studies revealed an unremarkable white blood cell count, lactate of 1.5, and liver function tests showing an aspartate aminotransferase (AST) of 56, alanine aminotransferase (ALT) 54, and alkaline phosphatase of 173. The international normalized ratio (INR) was 1.2, but the partial thromboplastin time (PTT) was slightly elevated to 39.5. Renal function and electrolytes were unremarkable. A right upper quadrant ultrasound showed thickening of the gallbladder wall, some pericholecystic fluid. The general surgery team was asked to evaluate the patient. They assessed the patient and felt the symptoms are not congruent with acute cholecystitis. The patient was given a dose of ceftriaxone and Flagyl in the emergency department before admission.

The surgery team reassessed the patient and described the pain was being controlled, with no nausea vomiting, and reports of chronic diarrhea. The abdomen was benign on the exam. The patient was tolerating a diabetic diet. The majority of the evaluation was guided by psychiatry. The social worker determined that the patient was homeless and initiated the process for placement at an adult care center. The social worker discussed with psychiatry who deemed the patient not to meet inpatient psychiatric admission criteria at that time.
The patient remained in the hospital for the next two days, with controlled pain, stable vital signs, and relatively stable blood work. Eventually he was deemed stable to transfer to inpatient psychiatry. He remained verbally abusive, refused many of his medications, and continued to require a sitter for unpredictable behavior.

The multidisciplinary team met, discussing the patient was discharged to inpatient psychiatry. The following day the patient was alert, and verbally responsive. Again, he refused Depakote and Topamax but was calm and ambulating in the hallways. He continued to decline ongoing care. The neurologist changed the medications again to a higher dose of Depakote, instead of Topamax. At this point, the patient is deemed stable for transfer to inpatient psychiatry and was safely discharged to that level of care.

The health plan's determination is upheld in whole. 

The requested health service/treatment of inpatient stay is not medically necessary for this patient, based on the presentation of abdominal pain with diarrhea.
The patient presented to the hospital with right upper quadrant pain and three days of diarrhea, non-bloody, with stable vital signs and relatively stable laboratory studies. Right upper quadrant ultrasound was equivocal, and the surgical team did not deem the patient to have acute cholecystitis. CT scan of the abdomen and pelvis was also non-acute. Diarrhea was resolved with a simple treatment with Imodium. Therefore, at this point, the work-up for the presenting symptom is completed, and the patient no longer required inpatient hospitalization.
There was no evidence of obstructing calculus, hemodynamic instability, persistent nausea or vomiting, or signs of dehydration. Per CT scan, the patient had evidence of a cirrhotic liver, which can give the gallbladder and the appearance of acute cholecystitis without the actual presence of acute cholecystitis. On hospital day 2, the patient was already on a diabetic diet and eating without difficulty.
The rest of the hospital stay was primarily for psychiatric evaluation. He spent the next five days, refusing medications, being evaluated by psychiatry to determine appropriate disposition home versus inpatient psychiatric unit. Eventually, he was deemed to require inpatient psychiatric hospitalization. In the midst of all this, he suffered a single seizure event. This was not a first-time seizure, patient with prior history of seizure disorder, poor compliance with antiepileptic medications, due to psychiatric history. The seizure event spontaneously resolved, and the patient did not require prolonged monitoring in the hospital for evaluation or treatment of the seizure disorder. As a result, inpatient hospitalization is not indicated.