Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld.

The patient is a woman who presented to the hospital with the complaint of one month of intermittent abdominal pain/biliary colic.  Vital signs were normal at the time of presentation.  Lab data identified a white blood cell (WBC) count of 15,000 with normal liver enzymes.  Abdominal ultrasound showed a gallstone, but no gallbladder wall thickening or pericholecystic fluid.  She was diagnosed with cholelithiasis/cholecystitis.  The patient was initially treated with pain medication, intravenous (IV) fluid and antibiotics.  Surgery was performed.  The operative dictation describes performance of  laparoscopic cholecystectomy.  

The patient's post-surgical course was uncomplicated.  Diet was advanced.  Pain medications were converted to oral medication.  The patient was discharged home the following day.  

The health plan rationale for denial of inpatient care was based on Milliman Care Guidelines (MCG) for Cholecystectomy by Laparoscopy.

No, the proposed acute inpatient admission was not medically necessary.
This patient presented to the hospital with cholelithiasis/cholecystitis.  She was clinically stable at the time of presentation to the Emergency Department.  Lab data identified a leukocytosis with a normal hepatic panel.  Laparoscopic cholecystectomy was performed without complication.  Following surgery, the patient remained stable and was able to tolerate a diet and oral pain medications.

The records support that there was no toxicity, significant active comorbidities, hemodynamic instability, inability to tolerate oral intake, pain management issues, or complications from the procedure.  The patient was able to be discharged from the hospital on the first post-surgical day.

Based on this patient's presenting condition and peri-operative course, the provided care could have been rendered at a lower level.

An inpatient designation is needed when there is failure to achieve discharge status criteria; conversion to open surgery; severe systemic infection; care for active comorbidities; calculus or obstruction of gallbladder or bile duct and one or more of the following: hemodynamic instability, common bile duct obstruction diagnosed by imaging, vomiting that is severe, dehydration that is severe or persistent, severe pain, bacteremia; and/or complications of the procedure.

In this case, the submitted documentation does not support that these clinical conditions existed to warrant an inpatient level of care.

Acute inpatient hospitalization was not medically necessary for this patient.  The medical records support that this patient could have been reasonably and safely monitored at a lower level of care.  

Based on this patient's presenting condition and peri-operative course, the provided care could have been rendered at a lower level.  The records support that the patient was treated in an expeditious and efficient manner.  The patient was clinically stable at the time of Emergency Department evaluation.  She required an operative procedure (laparoscopic cholecystectomy).  However, inpatient care was not medically necessary.  A lower level of care would have satisfied the clinical needs of this patient.  This lower level of care would have provided for pre-surgical evaluation, surgery and overnight post-operative monitoring.