Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain

Treatment: Hospital admission

The insurer denied coverage for hospital admission.

The denial is upheld.

The patient has gastroesophageal reflux disease (GERD), asthma, ulcerative colitis, hiatal hernia status post repair with sudden onset sharp epigastric pain, radiating substernally and into her back. Notes in the emergency department (ED) indicate pain was improving without treatment prior to arrival. She was afebrile, abdomen was soft with epigastric tenderness. The ultrasound revealed cholelithiasis. There was no sonographic Murphy's sign and the common duct was normal in size. Lab studies revealed a white blood count (WBC) of 11.9, normal lipase, normal liver function tests (LFT). The patient was admitted for plan for hepatobiliary iminodiacetic acid (HIDA) scan. The pain improved and she requested a trial of diet, which she tolerated. The HIDA scan was apparently not done due to resolution of her symptoms. She was discharged home on pain medication and antibiotics after the initiation of intravenous antibiotics, intravenous fluids and further evaluation.

The hospital admission is not considered medically necessary for this patient. Acute cholecystitis refers to a syndrome of right upper quadrant pain, fever, and leukocytosis associated with gallbladder inflammation and is usually related to gallstone disease. This patient presented with symptoms that resolved with negligible treatment and no findings consistent with acute cholecystitis. This patient could have been managed with a period of observation. There was no need for an acute inpatient admission. 

"Management of gallstones can be divided into two categories: asymptomatic gallstones and symptomatic gallstones. Asymptomatic gallstones require the patient to be counseled regarding symptoms of biliary colic and when to seek medical attention. Cholelithiasis without complications can be treated acutely with oral or parenteral analgesia in the emergency department or urgent care center once the diagnosis has been established and alternative diagnoses excluded." (Tanaja, J, et al)

"The accurate differentiation of gallstone-induced biliary colic from other abdominal disease processes is the most crucial step in the successful management of gallstone disease. Despite the availability of many imaging techniques to demonstrate the presence of gallstones, clinical judgment ultimately determines the association of symptoms with cholelithiasis and its complications. Adult patients with silent or incidental gallstones should be observed and managed expectantly, with few exceptions. In symptomatic patients, the intervention varies with the type of gallstone-induced complication. In this article, we review the salient clinical features, diagnostic tests and therapeutic options employed in the management of gallstones and their complications." (Ahmed, A, et al)   

The health care plan did act reasonably, with sound medical judgment, and in the best interest of the patient.                                                             

The insurer's denial of coverage for hospital admission is upheld. Medical necessity is not substantiated.