Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld

This patient is a woman. She presented to the hospital with symptoms of abdominal pain and vomiting.  She had recently undergone treatment for cholelithiasis and with cholecystectomy, two weeks prior to this presentation.

The patient's past medical history is significant for no other medical problems.  The ED (emergency department) evaluation identified normal vital signs (heart rate of 71/minute and temperature of 98.8 Fahrenheit).  There was abdominal tenderness in the right upper quadrant.  The WBC (white blood cell) count was normal (3.2 K [thousand]).  Liver enzymes showed elevated transaminases with normal bilirubin.  CT (computed tomography) scan showed post-surgical changes of cholecystectomy mild free fluid in the peritoneal cavity thought to by physiologic.  Initial treatment included IV (intravenous) fluid and pain medications.

The patient was admitted to the hospital.  She was evaluated with abdominal ultrasound and MRCP (Magnetic Resonance Cholangiopancreatogram).  Gastroenterology consultation was obtained.  The MRCP (Magnetic Resonance Cholangiopancreatogram) showed a 10-mm (millimeter) common duct without common duct stones.  No further GI (gastrointestinal) workup was advised.   The progress notes that correspond document normal vital signs.  The elevated liver enzymes did progressively normalize over this period of time.

The patient was started on a diet. Her pain resolved and she was discharged from the inpatient setting.  The etiology of her symptoms was attributed to hepatitis related to biliary obstruction that resolved.

The health plan rationale for denial of inpatient level of care, per the denial letter, is that there were no indications for need of inpatient admission per MCG (Milliman Care Guidelines) for abdominal pain such as bowel blockage, severe dehydration, need for immediate surgery or other clinical issue that mandated inpatient care.

No, the Inpatient admission was not medically necessary.
This patient was admitted to the hospital with abdominal pain. She was two weeks post laparoscopic cholecystectomy. Vital signs were normal at presentation. Lab data did show elevated liver enzymes with normal bilirubin. MRCP (Magnetic Resonance Cholangiopancreatogram) was ordered but was not completed until the day of discharge. It showed no common bile duct stones and GI (gastrointestinal) consultation yielded the recommendation for no intervention. The Vital signs remained normal during the period of observation until discharge. The submitted medical records support that a lower level of care would have provided for the necessary evaluation in the ED (emergency department) and follow up care until the patient's discharge.

Inpatient level of care was not medically necessary. A lower level of care would have permitted for ED (emergency department) assessment, IV (intravenous) fluid, imaging, surgical and GI (gastrointestinal) evaluations, and overnight monitoring. The patient was clinically stable at the time of presentation and remained so during the period of overnight monitoring as supported by the corresponding medical records and progress notes.

Yes, the health plan did act reasonably, with sounds medical judgment, and in the best interest of the patient.
The submitted records do not support the medical necessity of acute inpatient stay.

In this case there was no significant vital sign abnormality, vomiting that is persistent after ED (emergency department) treatment, significant electrolyte or metabolic abnormality, pain persistent after ED (emergency department) treatment, or significant post-surgical complication.  In this case the documentation supports a lower level of care.