Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Inpatient Hospital. 
The insurer denied Inpatient Stay. 
The denial is upheld. 

The patient at the time of presentation was a female with an unremarkable past medical history who presented to the hospital with right upper quadrant pain that had been going on for a week. She also had epigastric abdominal pain that radiated to the back and was associated with emesis. The patient reported having intermittent episodes of biliary colic within the last year. She reported occasional postprandial right upper quadrant pain and nausea. She denied fever, chills, chest pain, shortness of breath, and diarrhea. When the patient was seen by the admitting physician, she was afebrile. Pulse rate was 93 beats per minute (bpm), respiratory rate was 18 breaths per minute, blood pressure was 131/80, and oxygen saturation was 99% on room air. The patient was in no acute distress and looked comfortable. Breathing was nonlabored. The abdomen was soft, non-distended, with right upper quadrant tenderness, without rebound or guarding.
On the laboratory evaluation, the white blood cell count was 5.0, hemoglobin was 13.4, hematocrit was 37.9, and platelets were 221. The sodium was 140, potassium was 4.0, chloride was 104, bicarbonate was 24, blood urea nitrogen (BUN) was 10, creatinine was 0.93, and glucose was102. Alkaline phosphatase was 290, aspartate aminotransferase (AST) was 671, and alanine aminotransferase (ALT) 989. Total bilirubin was 6.3.
It was reported that initially, she tested positive for coronavirus 2019 (COVID-19). A right upper quadrant ultrasound revealed sludge in the gallbladder without evidence of cholecystitis. The common bile duct looked normal. The patient was admitted to the hospital and was ordered a magnetic resonance cholangiopancreatography (MRCP) and gastrointestinal (GI) service was consulted.
The patient did not require urgent intervention. Her total and direct bilirubin were steadily declining. The abdominal pain was well controlled, and the patient tolerated a regular diet. The MRCP performed in the hospital showed no intra-or extrahepatic biliary tree dilatation. There was no common bile duct (CBD) stone. She received treatment with antibiotics while in the hospital and was discharged home with antibiotics for another week.
At issue is the medical necessity of Inpatient Stay.

The health plan's determination of medical necessity is upheld in whole.

The requested health service/treatment of Inpatient Stay was not medically necessary for this patient.
There was no compelling clinical reason why the patient required admission to an inpatient level of care. The review of the medical records demonstrates that the patient had no systemic signs of inflammation including fever, significant elevation of C-reactive protein (CRP), or leukocytosis. There was no evidence that the patient had acute cholecystitis, hemodynamic instability, common bile duct obstruction, severe or persistent vomiting, dehydration, or severe pain requiring inpatient management. This patient had an elevated bilirubin and transaminases however; this did not prompt any interventions that would justify admission at the acute inpatient level of care. Overall, this patient remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating the inpatient level of care.
Therefore, the requested health service/treatment of Inpatient Stay was not medically necessary for this patient.