Appeal type: Medical necessity
Decision: Upheld

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

The patient is a woman. She presented to the hospital with abdominal pain of four days duration. The patient's comorbid health conditions included hypertension and morbid obesity (BMI [body mass index] 40 kg/m2 [kilograms per meters squared]).

At the time of presentation, the patient was without fever, and her vital signs showed a normal heart rate and elevated blood pressure. She was tender in the right upper abdomen. The WBC (white blood cell) count was normal at 4.5 K (thousand). The complete metabolic panel identified elevated serum transaminases, bilirubin, and alkaline phosphatase. Ultrasound showed gallstones, a mildly thick gallbladder wall and a 3-mm (millimeter) common bile duct (CBD). Intra and extra-hepatic ducts were not dilated. MRCP (Magnetic Resonance Cholangiopancreatogram) was performed and showed no CBD (common bile duct) stones.

The patient was initially treated with IV (intravenous) fluid, pain medications and anti-emetics. She was treated with laparoscopic cholecystectomy. The operative dictation and the anesthetic record describe an uncomplicated cholecystectomy procedure.

The patient was treated with post-surgical monitoring, IV (intravenous) fluid, IV (intravenous) analgesia, and antiemetics. The immediate post-surgical recovery was uncomplicated. Following surgery, the patient had stable vital signs. Pain was controlled. The diet was advanced. The patient remained clinically stable and was discharged from the inpatient setting.

The health plan letter references MCG (Milliman Care Guidelines) 24th edition Gallbladder or Bile Duct Inflammation.

No, the Inpatient admission was not medically necessary.

This patient is woman who presented to the hospital with cholelithiasis/cholecystitis.  There is no documentation of hemodynamic, pulmonary, neurological, or metabolic reason for an acute inpatient level of care.  Additionally, there is no documentation of failure to achieve discharge criteria, conversion to open surgery, care for comorbidities, procedural complications, or any other condition requiring inpatient admission.  Acute inpatient care was not medically necessary for this patient, as the care and treatment provided could have been rendered in the observational setting.  An observational level of care would have provided for ED (emergency department) assessment, surgical and gastroenterology assessments, imaging with ultrasound and MRCP (Magnetic Resonance Cholangiopancreatogram), perioperative care and monitoring, provision of IV (intravenous) fluid and medication, and overnight care.

There is no compelling reason documented as to why this patient could not have been safely and appropriately treated at the observation level of care. Based on the submitted clinical documentation, an inpatient level of care was not medically necessary. This patient was admitted to the hospital on  with the diagnosis of cholelithiasis/cholecystitis. Her presurgical assessment and the indication for surgery was established. 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 (intravenous) fluid, IV (intravenous) antibiotics, IV (intravenous) antiemetics, and post-surgical monitoring. The patient was clinically stable following surgery as supported by the corresponding medical records.

An inpatient level of care was not required for the care and treatment of this patient. The medical record supports that the patient could have been reasonably and appropriately treated with an observation level of care.