Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient is an adult female (body mass index [BMI] 29 kilograms per meter squared [kg/m2]) who presented to the emergency department with complaint of right upper abdominal pain. Her past medical history is notable for no chronic medical health conditions. She had been seen at another hospital the day prior to this presentation with the same complaints and had been evaluated with ultrasound that identified gallstones and a thickened gallbladder wall. The patient was admitted to the hospital. Her vital signs were normal at the time of presentation. She was tender in the right upper quadrant. The surgical history and physical (H&P) document a normal white blood cell (WBC) count of 6.9 thousand (K) with normal liver enzymes and bilirubin. Laparoscopic cholecystectomy was recommended and planned. The patient was started on intravenous (IV) antibiotics.
Surgery was performed the next day. The operative notes describe laparoscopic cholecystectomy that was performed without complication. On the day following surgery the diet was advanced and pain was controlled with oral medications. On day #3, the patient's vital signs were normal. The patient remained clinically stable and was discharged from the inpatient setting.
The material submitted for review includes the health plan denial letter. This letter states that inpatient admission to the hospital was not needed in this case following gallbladder surgery. This letter references Milliman Care Guidelines (MCG)-Surgery.

The proposed treatment was not medically necessary.

Inpatient care was not medically necessary in this case. The care provided could have been rendered with a lower level of care. A lower level of care would have provided for initial assessment, perioperative care and monitoring, provision of intravenous fluid, surgical consultation, and performance of cholecystectomy. There was no peri-procedure complications or other clinical issues. 
Inpatient care may be needed when there is:
* Acute cholangitis with systemic signs of sepsis and evidence of common bile duct disease with bilirubin greater than (>) than 2 milligrams per deciliter (mg/dl) or aspartate aminotransferase 
(AST) / alanine aminotransferase (ALT) 1.5 times upper limit of normal, or imaging showing biliary dilatation or evidence of etiology.
* Acute cholecystitis (right upper quadrant pain or tenderness, systemic signs of inflammation, cholecystectomy not anticipated due to high surgical risk or plan for interval cholecystectomy).
Also, criteria for inpatient admission may include:
* Failure to achieve discharge criteria
* Conversion to open surgery
* Severe post-operative infection
* Care for active comorbidities
* Complications of procedure
* Gallstone ileus.
In this case, the patient presented with symptoms related to cholecystitis. The evaluation and the indication for cholecystectomy was established presentation. The cholecystectomy procedure was performed the next day without complication and the patient was stable for discharge from the hospital on the first post-surgical day. The patient responded promptly and without complication to the prescribed therapy (cholecystectomy). The above noted conditions did not exist to warrant an inpatient level of care. The patient's presenting condition at the hospital and clinical course did not justify an inpatient level of care. The care provided could have appropriately been rendered with a lower level of care.