Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Inpatient Hospital. 

The insurer denied the Inpatient Hospital Stay. 
The determination is overturned. 

The patient presented to the emergency department (ED) with abdominal pain and jaundice. He had a past medical history that included known gallstones. At the time of presentation, the patient was without a fever, the heart rate was 77 and blood pressure was 159/96 millimeters of mercury (mmHg). He was tender in the upper abdomen. The white blood cell count (WBC) count was 7.9 thousand (K). The complete metabolic panel identified an elevated bilirubin (6.6). An abdominal computed tomography (CT) scan showed gallstones and a dilated common bile duct (CBD) with a distal CBD stone. Magnetic resonance cholangiopancreatography (MRCP) also showed CBD stones. 
A gastroenterology consultation was obtained and the patient underwent an endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and stone extraction. The patient remained stable following the ERCP. The patient underwent a laparoscopic cholecystectomy. The operative dictation describes cholecystitis. He was clinically stable following surgery and was treated with post-surgical monitoring, intravenous (IV) fluid, IV analgesia, and antiemetics. The immediate post-surgical recovery was uncomplicated. On post-operative day number (#) 1 following surgery, the patient had stable vital signs. The pain was controlled with oral medications. His diet was advanced. The patient remained clinically stable and was discharged from the inpatient setting. At issue is the medical necessity of an inpatient stay. 

An inpatient level of care was medically necessary in this case and consistent with the diagnoses of choledocholithiasis and cholelithiasis/cholecystitis and with the generally accepted guidelines. 

This patient presented to the hospital with cholelithiasis and choledocholithiasis (elevated total bilirubin and image confirmation of CBD stones). Based on the presenting lab and imaging data, it was reasonably anticipated that the medically necessary care would span a period of greater than 48-hours. The patient was appropriately started on intravenous (IV) antibiotics and was appropriately imaged with an MRCP. This study confirmed common bile duct stones that were cleared with an ERCP. Surgery was appropriately performed (laparoscopic cholecystectomy) and the patient was clinically stable for discharge from the hospital on the first post-surgical day. 

An inpatient stay is needed when there is: failure to achieve discharge status criteria, conversion to open surgery, severe systemic infection, care for active comorbidities, calculus or obstruction of gallbladder or bile duct and one or more of the following: hemodynamic instability, CBD obstruction diagnosed by imaging, vomiting that is severe, dehydration that is severe or persistent, severe pain, bacteremia, complications of the procedure. 

In this case, the submitted documentation does support that these clinical conditions (Calculus or obstruction of gallbladder or bile duct and CBD obstruction diagnosed by imaging) existed to warrant an inpatient level of care. 
The records support that the patient was treated in an expeditious and efficient manner. His condition required the coordinated, inpatient care, of the gastroenterology and surgery services. He required two procedures (ERCP and cholecystectomy) to appropriately treat his condition of cholelithiasis and choledocholithiasis. Inpatient care was appropriate, consistent with medical standards and a lower level of care would not have satisfied the clinical needs of this patient.