Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Abdominal Pain.
Treatment:  Inpatient Hospital Stay. 
The insurer denied the Inpatient Hospital Stay.  The determination is upheld.

The patient presented to the hospital with abdominal pain and back pain of 3-days duration in the setting of known gallbladder disease.  The patient has a history of prior gastric bypass surgery performed as a bariatric operation.  At the time of presentation, the patient was without a fever and vital signs were normal.  Lab data showed a normal white blood cell count (WBC) count and normal liver enzymes.  A computed tomography (CT) scan identified biliary disease.  She underwent a laparoscopic cholecystectomy.  The operative dictation and the anesthesia record describe intra-abdominal adhesions and a chronically inflamed gallbladder.  A laparoscopic cholecystectomy and lysis of adhesions was performed.  The operation took approximately 1 hour 45 minutes to complete.

The patient was treated with post-surgical monitoring, intravenous (IV) fluid, IV analgesia, and antiemetics.  The immediate post-surgical recovery was notable for good control of pain and nausea.  On post-operative day number (#) 1 following surgery, the patient had stable vital signs.  Her pain was controlled.  Her diet was advanced.  The patient remained clinically stable and was discharged from the inpatient setting.  There is no clinical documentation to support the need for an inpatient admission or why this patient could not have safely and appropriately been treated at a lower level of care.

This patient was admitted to the hospital with the diagnosis of cholelithiasis/biliary colic.  The patient underwent an uncomplicated laparoscopic cholecystectomy procedure.  There were no peri-operative complications or other clinical issues.  She remained stable and was discharged from the hospital.

Inpatient level of care was not medically necessary.  An observation level of care would have permitted for the pre-surgical assessment, the surgical procedure and perioperative IV fluid, IV antibiotics, IV antiemetics, and post-surgical monitoring.  The patient was clinically stable following surgery, as supported by the corresponding medical records.

The submitted records document that this patient was clinically and hemodynamically stable at the time of presentation.  Surgery was performed and the perioperative period was uncomplicated.  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 care is indicated when there is right upper quadrant pain and systemic signs of inflammation (fever, C-reactive protein greater than [>] 10, WBC count > 10 thousand [K]).  Inpatient admission is also 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.

In this case none of these indications existed to justify an inpatient level of care.