Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal/stomach pain. 
Treatment: Inpatient hospital admission. 
The health plan denied the inpatient hospital admission. 
The determination is upheld. 

The patient is a female who presented to the emergency department (ED) with left flank pain. The patient reported that the pain was intermittent but had been becoming worse. The patient was having associated nausea. Her vital signs demonstrated a pulse of 111 beats per minute (bpm) on presentation; otherwise, her vital signs were unremarkable. The tachycardia resolved in the ED. The patient was noted to have left costovertebral angle (CVA) tenderness on exam. Her white blood cell (WBC) count was 5.1. Her liver function tests (LFTs) were mildly elevated. A computed tomography (CT) scan demonstrated pericholecystic fluid and wall thickening. The patient was hospitalized, and a laparoscopic cholecystectomy was planned. During surgery, an inflamed gallbladder was identified and removed without complication. The patient was kept in the hospital after the procedure. Her labs were checked the next day, which were as expected. The patient met discharge criteria and was discharged home. 
At issue is the medical necessity of the inpatient hospital admission. 
The health plan's determination of medical necessity is upheld in whole. 
The requested health service/treatment of inpatient hospital admission is not medically necessary for this patient. Per the Milliman Care Guidelines (MCG), inpatient admission is indicated for acute cholangitis, acute cholecystitis when cholecystectomy is not anticipated, and for calculus or obstruction of the gallbladder with certain complications. The patient does not meet criteria for acute cholangitis, as this requires systemic signs of inflammation and evidence of common bile duct disease. The patient does not meet criteria for acute cholecystitis with signs of systemic inflammation or where cholecystectomy is not anticipated. The patient did not have a fever, C-reactive protein elevation, or WBC count elevation. The patient does not meet criteria for calculous or obstruction of the gallbladder or bile duct with hemodynamic instability, common bile duct obstruction, vomiting that is severe or persistent, severe pain requiring acute inpatient management, or bacteremia. 
The patient also does not meet MCG criteria for undiagnosed abdominal pain which requires hemodynamic instability, severe pain, peritoneal signs, identification of an etiology that requires inpatient care, nothing by mouth (NPO) status greater than (>) 24 hours requiring significant intravenous (IV) fluid support, suspected toxic megacolon, bacteremia, a procedure that cannot be performed on an ambulatory basis, or parenteral nutrition. The documentation does not suggest that the patient's care could not have been performed at an alternate level of care. There is no evidence that additional complex testing or therapy other than the procedure was performed. There is no documentation that the treating team identified conditions or problems specific to the patient that would have required inpatient care. Therefore, the provided documentation does not support the medical necessity of inpatient level of care.