Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient hospital admission.
The denial is upheld.

The patient is a female who presented to the emergency department (ED) with right upper quadrant abdominal pain and symptoms related to her known gallbladder disease. She had previously been admitted to the hospital for these complaints. Past medical history included hyperlipidemia and asthma. At the time of presentation the patient was without fever and the heart rate was 95/minute. She had a tender right upper abdomen per the examination. The white blood cell (WBC) count was 12.4 thousand (K). The complete metabolic panel identified elevated transaminases with normal bilirubin. Ultrasound (previously performed) showed findings of gallstones. An ultrasound exam showed an impacted stone in the neck of the gallbladder and a normal caliber common bile duct. She was treated with laparoscopic cholecystectomy. The records indicate an uncomplicated cholecystectomy procedure with findings of cholecystitis.

The patient was treated with post-surgical monitoring, intravenous (IV) fluid, IV analgesia, and antiemetics. The immediate post-surgical recovery was uncomplicated. Pain was controlled with oral medications following surgery. The diet was advanced. The patient remained clinically stable and was discharged from the inpatient setting.

The health plan's determination is upheld.

This patient is a female with known gallbladder disease who presented to the hospital with cholelithiasis/cholecystitis. She was tender in the right upper quadrant and had slight elevation of transaminases. Based on her clinical condition and diagnostic test results, the indication for cholecystectomy was established. However, 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, procedural complications, or any other condition requiring inpatient admission. 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 assessment, surgical consultation, cholecystectomy, perioperative care and monitoring, provision of IV antibiotics and fluid, and overnight care. The submitted records document that this patient was clinically and hemodynamically stable at the time of presentation. The perioperative period was uncomplicated, and the patient was discharged from the hospital on the first post-surgical day.

Inpatient stay may be needed for failure to achieve discharge status criteria, conversion to open surgery, systemic infection, care for active comorbidities, complications of procedure. In this case none of these conditions existed to warrant an inpatient level of care. Inpatient admission may also be indicated for acute cholangitis, common bile duct obstruction, vomiting that is severe or persistent, dehydration that is severe or persistent, hemodynamic instability, severe pain requiring acute inpatient management, signs of intestinal obstruction, bacteremia, need for percutaneous or open procedures, or other condition that requires inpatient admission.