Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain. 
Treatment: Inpatient admission. 

The insurer denied: Inpatient admission. 
The denial is upheld. 

The patient is an adult male who presented to the hospital ED (emergency department) with new onset right upper abdominal pain, nausea, and vomiting of 1-day duration. Comorbid health conditions included high cholesterol. 
At the time of presentation, the patient was without fever and vital signs were normal. He was tender in the right upper quadrant. The WBC (white blood cell) count was elevated at 19 K (thousand). The complete metabolic panel identified slightly elevated liver enzymes and normal bilirubin. Abdominal ultrasound showed gallstones within the gallbladder and wall thickening. He was admitted to the hospital. The patient was evaluated with surgery consultation. He was treated with IV (intravenous) fluid, NPO (nothing by mouth) status, and IV (intravenous) antibiotics. The patient underwent laparoscopic cholecystectomy. The operation was performed without complication. The diet was advanced following surgery and pain was controlled with oral medications. The patient remained clinically stable and was discharged from the inpatient setting with planned short term follow up. The health plan rationale for denial of coverage of the inpatient admission letter references MCG (Milliman Care Guidelines). This letter states that the patient died not have a situation, condition, or finding before surgery that required an inpatient stay. Nor was there a postoperative condition that required inpatient admission. There were no complications of the procedure. This letter states that the care provided could have been rendered in the ambulatory setting. The denial is being appealed. 

The Inpatient admission was not medically necessary. 

An inpatient level of care was not medically necessary in this case. This is an adult male who presented to the hospital with abdominal pain. He was determined to have cholelithiasis/cholecystitis. There is no documentation of hemodynamic, pulmonary, neurological, or metabolic reason for an acute inpatient level of care. Additionally, there is no documentation of failure to achieve discharge criteria, conversion to open surgery, care for comorbidities, or any other condition requiring inpatient admission. The indication for cholecystectomy was established. The patient admitted to the hospital. He underwent surgery to remove the gallbladder. The patient responded favorably to treatment and was stable for discharge from the hospital with planned follow up. Acute inpatient care was not medically necessary for this patient as the care and treatment provided could have been rendered with a lower level of care. A lower level of care would have provided for ED (emergency department) assessment, surgical assessment and monitoring, laparoscopic cholecystectomy, provision of IV (intravenous) antibiotics and fluid, and overnight care. 

The health plan rationale for denial of coverage of the inpatient admission letter references MCG (Milliman Care Guidelines). This letter states that the patient died not have a situation, condition, or finding before surgery that required an inpatient stay. Nor was there a postoperative condition that required inpatient admission. There were no complications of the procedure. This letter states that the care provided could have been rendered in the ambulatory setting. In this case, the health plan contention that the care provided could have been rendered with a lower level of care is accurate and consistent with current medical standards.