Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cholangitis

Treatment:  Inpatient stay

The insurer is denied coverage for inpatient stay.

The denial is upheld. 

This female patient has a history of pancreatitis, asthma, nephrolithiasis, cholecystectomy, tubal ligation, diverticulitis, and anxiety. The patient presented to the Emergency Department (ED) for left upper quadrant (LUQ) abdominal pain radiating to the right upper quadrant (RUQ). The patient reported that the pain was associated with nausea and vomiting. In the ED, the patient was tachycardic, and febrile to 39 degrees Celsius. The patient received hydromorphone and morphine for pain. The patient was started on intravenous (IV) Zosyn and received 2 IV boluses of normal saline 1000 milliliters (mL). The patient's nausea was treated with metoclopramide and Zofran. The patient's ultrasound of the abdomen was obtained and did not show biliary dilation. The patient's labs were significant for leukocytosis and elevated liver enzymes. Gastroenterology was consulted and there was an initial concern for cholangitis. The patient was admitted to the Intensive Care Unit (ICU) for a concern of sepsis secondary to cholangitis. The patient's magnetic resonance cholangiopancreatography (MRCP) and abdominal magnetic resonance imaging (MRI) were ordered to rule out cholangitis. MRCP did not show significant biliary tree dilation or calculi in the biliary tree. The patient was intermittently febrile throughout admission. The patient was afebrile and was hemodynamically stable. Radiology results were negative for cholangitis. The patient was transferred to the general medical floor. The patient was discharged home. The patient's blood cultures were pending at the time of discharge.

Upon review it was noted the patient did not have acute cholangitis. However, the patient did require a workup to see if she had cholangitis. MCG has a guideline for gall bladder or bile duct inflammation or stone observation care. This category is advised when there is a vital sign abnormality, vomiting or pain that persists despite emergency department care and a suspected acute cholangitis when further immediate evaluation is needed to clarify the diagnosis (OC-055). The patient met these criteria for observation care in view of the need for a workup for cholangitis.

Clinical indications for admission for sepsis and other febrile illness without focal infection (M-160) include hemodynamic instability, hypoxemia, altered mental status tachypnea that does not improve after observation care and fever above 104.9. In this case, the patient did not have these conditions.

Based on the review of the medical record and literature, hospital admission was not medically necessary for this patient. This patient required a workup but did not have acute cholangitis. Intravenous hydration, a culture and intravenous antibiotics could have been given under observation status. The patient's condition met the criteria for observation status to evaluate for a possible cholangitis. However, the patient did not have acute cholangitis or meet the MCG criteria for acute care for sepsis and other febrile illness. Thus, hospital admission was not medically necessary for this patient.

The health plan did act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the inpatient hospital admission is upheld.  The medical necessity is not substantiated.