Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is: Upheld.

The patient is a male with a past medical history significant for hyperlipidemia, diabetes mellitus, hypertension, and coronary artery bypass graft (CABG) who presented to the hospital with epigastric abdominal pain for 3 days. The epigastric abdominal pain was intermittent and aggravated after his meals. The patient described the pain as tightness. It was non-radiating. The patient denied fever, chills, chest pain, shortness of breath, and leg pain. The patient also denied nausea, vomiting, diarrhea, urinary symptoms, palpitations, recent travel, or any immobility. The patient admitted to having decreased exercise tolerance.
During the hospital stay, the patient was seen by a gastroenterologist who stated that the patient had cholelithiasis but normal bilirubin and normal common bile duct. The gastroenterologist mentioned that, even though a computed tomography (CT) scan of the abdomen demonstrated mild pancreatitis, the patient was completely asymptomatic at the time of the consultation. The gastroenterologist stated that the patient did not meet the criteria for acute pancreatitis.
The gastroenterologist suggested that the patient's abdominal pain could be related to gastritis or biliary colic. Again, it was emphasized in the consultation note that all the symptoms resolved. The patient was recommended treatment with Pantoprazole daily.
As far as the pancreatic cyst, the patient was recommended to repeat a CT scan of the abdomen or magnetic resonance imaging (MRI) in 6 months.
The patient was also seen by a cardiologist. There was no evidence of any acute cardiac problems or a need for any inpatient procedure.
During the hospital stay, the patient was diagnosed with mild hyponatremia and was recommended fluid restriction and a follow-up with primary care physician (PCP).
The patient's clinical condition improved, and he was discharged from the hospital.

The inpatient hospital admission was not medically necessary for this patient.
The patient presented to the hospital with abdominal pain that was not associated with hemodynamic instability or peritoneal signs. There was no evidence that the pain was severe enough to justify admission at the acute inpatient level of care.
There was no evidence that the abdominal pain was the result of serious medical conditions such as aortic dissection, bowel perforation, bowel ischemia, visceral organ torsion, or intestinal obstruction. There was no mention that the abdominal pain was associated with bacteremia or toxic megacolon. The evaluation of the abdominal pain did not require the patient not to eat or drink for an extended period of time.
Therefore, there is no reason why the severity of the patient's condition or the complexity of the services provided rose to the acute inpatient level of care.
The abdominal pain, was most likely related to cholelithiasis and biliary colic, which resolved.
Overall, this patient remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care. 
This determination coincides with Milliman Care Guidelines (MCG) Health Inpatient & Surgical Care 24th Edition criteria for gallbladder or bile duct inflammation of Stone. These criteria were attached to the chart for review. These criteria are relevant since the patient's symptoms were most likely related to biliary colic. Based on these criteria, the cholelithiasis was not associated with hemodynamic instability, common bile duct obstruction, severe or persistent vomiting, severe or persistent dehydration, severe pain requiring acute inpatient treatment, or bacteremia.