Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain
Treatment: Inpatient admission
The insurer denied coverage for an inpatient admission
The denial is upheld

This is the case of a female with a history of HTN (hypertension), arrhythmia, anxiety, diabetes, and bariatric surgery who presented to the emergency department (ED) with three days of RUQ (right upper quadrant) abdominal pain. The patient denied vomiting but did complain of nausea. She was afebrile with a Heart Rate of 87, Blood Pressure 148/98. Abdominal exam revealed the abdomen to be soft without distension. There was abdominal tenderness in the RUQ. There was no cerebrovascular accident (CVA) tenderness, abdominal guarding or rebound. WBC (white blood cell count) was 13.15 with total bilirubin of 0.3, ALT (alanine transaminase) of 29, AST (aspartate transaminase) of 20, and alkaline phosphatase of 94. A sonogram revealed cholelithiasis without evidence of gallbladder wall thickening or pericholecystic fluid; increased echogenicity of the liver parenchyma suggestive of fatty infiltration. The plan was for the patient to be NPO (nothing by mouth) and to receive IV (intravenous) fluids. The patient was admitted.

This reviewer believes that the patient did not need an acute inpatient admission and agrees with the insurer. According to the guidelines of MCG (Milliman Care Guidelines) Health Inpatient and Surgical Care- 26th edition Gall bladder or bile duct inflammation or stone ORG: M-555 patients may be discharged to a lower level of care (either later than or sooner than the goal) when it is appropriate for their clinical status and care needs. The  clinical indications for admission to inpatient care may include patients with 1 or more of the following: Acute cholangitis as indicated by ALL of the following: Systemic signs of inflammation indicated by 1 or more of the following: Fever, CRP (C reactive protein) level greater than 10 mg (milligrams)/L (liter), White blood cell count greater than 10,000/mm (millimeters)3 (10 x109/L) or less than 4000/mm3 (4 x109/L);  Evidence of common bile duct disease indicated by 1 or more of the following: Total serum bilirubin level greater than or equal to 2 mg/dL (34 micromoles/L), Liver function test (alkaline phosphatase (ALP), r-glutamyl transferase (GGT), aspartate aminotransferase (AST), or alanine aminotransferase (ALT)) greater than 1.5 times the upper limit of normal, Hepatobiliary imaging showing biliary dilatation or evidence of etiology (e.g., stricture, stone, previously placed stent); Acute cholecystitis as indicated by ALL of the following: Right upper quadrant pain, mass, or tenderness; Systemic signs of inflammation indicated by 1 or more of the following: Fever, C-reactive protein level greater than 10 mg/L, White blood cell count greater than 10,000/mm3 (10 x109/L) or less than 4000/mm3 (4 x109/L) and Cholecystectomy not anticipated (i.e., not during current hospital stay) due to 1 or more of the following: High surgical risk (e.g., severe comorbidities, organ failure), Interval cholecystectomy planned (i.e., not during current hospitalization); Calculus or obstruction of gallbladder or bile duct and 1 or more of the following: Hemodynamic instability, Common bile duct obstruction diagnosed (e.g., by imaging), Vomiting that is severe or persistent, Dehydration that is severe or persistent, Severe pain requiring acute inpatient management, Bacteremia. This patient did not need to be admitted as she could have been managed with an outpatient or ambulatory basis. The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage is upheld. Medical Necessity is not substantiated.