Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

This is the case of a patient who presented to the emergency department (ED) via car with the complaint of abdominal pain. As per the ED provider note, the patient complained of left lower quadrant (LLQ) pain with vomiting. The vital signs were stable, and the patient was afebrile. As per the history the patient has diabetes with a history of gallstones. The patient was scheduled to have an elective cholecystectomy later in the year. The patient was afebrile with stable vital signs. Exam revealed some abdominal tenderness in the right upper quadrant (RUQ) and epigastric area. There was no guarding. The assessment was symptoms consistent with biliary colic, and the plan was pain medication and sonogram.
 
Surgery did a brief admission noted and noted the history of gallstones and pain on and off for the last day. The patient was requesting to have the gall bladder removed. White Blood Cell (WBC) count was 14.62 and glucose was 239. The patient was admitted to surgery with plan for clear liquid diet and insulin coverage, pain medications and Zosyn. The plan was to medically optimize and perform surgery. Repeat WBC was 7.97 and glucose was 213. Liver function tests (LFT's) were normal. 

The surgical note indicated the patient had no acute events overnight and pain was well controlled on pain medications. The patient denied fever and was tolerating diet. The plan was for the operating room (OR) the following day with the working diagnosis cholelithiasis. The patient was taken to the OR and underwent an uneventful lap cholecystectomy. The gallbladder was thickened. Pathology revealed chronic cholecystitis with cholelithiasis. Following the cholecystectomy, the patient tolerated diet and voided, and was discharged to home that evening.

Based upon the records, acute inpatient admission was not justified as this patient should have been managed as noted by the insurer in an ambulatory/observation setting as they had an uneventful lap cholecystectomy for biliary colic and did not have acute cholecystitis. The patient did not have a significantly elevated WBC and did not have a fever. The patient did not have abnormal liver function tests. This patient had biliary colic and wanted their gallbladder to be taken out. The patient was kept in the hospital to be "medically optimized" and at the same time was given a diet. The patient should have had the gallbladder taken out on day 1 or day 2 and then sent home. It appeared that once the patient was admitted the decision was made to schedule the surgery for 48 hours later, when there was no indication that it could not and should not have been done sooner. This was being done for biliary colic which is done in an ambulatory setting. The patient presented now with increased pain and was taken this time for the lap cholecystectomy 2 days after presentation.  
 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for an inpatient admission is not substantiated.