Appeal type: Medical necessity
Decision: Overturned

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

The patient is a male who presented to the emergency department with worsening abdominal pain of two-days duration.  Comorbid health conditions included diabetes.  At the time of presentation the patient had a fever of 100.8 F (Fahrenheit) and vital signs were notable for hypertension with a blood pressure of 147/99 millimeters of mercury (mmHg).  The heart rate was 78 beats per minute.  He was tender in the right upper quadrant.  The white blood cell (WBC) count was elevated at 18.2 thousand.  The complete metabolic panel identified normal bilirubin and elevated serum transaminases.  Abdominal ultrasound and computed tomography scan showed gallbladder thickening consistent with acute cholecystitis.  

The patient was admitted to the hospital and initially treated with intravenous fluids, antibiotics, and antiemetics.  Surgery and medical consultation was obtained.  On day two, the patient was treated with laparoscopic cholecystectomy.  The operative dictation and the anesthetic record describe findings of acute gangrenous cholecystitis.  There was bile in the abdomen consistent with perforation of the gallbladder.  The procedure was completed without complication.  

The patient was continued on intravenous antibiotics post-operatively.  The white blood cell count was further elevated at 20.7 thousand day three.  The patient was treated with post-surgical monitoring, intravenous fluid, intravenous analgesia, and antiemetics.  The immediate post-surgical recovery was otherwise uncomplicated.  On day four, the patient was stable from the standpoint of the surgical service and he was discharged from the inpatient setting with continued oral antibiotics.

The hospital appeal letter references Milliman Care Guidelines.

Yes, the proposed inpatient hospital admission was medically necessary.
An inpatient level of care was medically necessary in this case.  

This patient is a male who presented to the hospital with acute cholelithiasis/cholecystitis.  Presurgical imaging and lab data supported the diagnosis of acute cholecystitis and the operative findings confirmed that there was acute gangrenous cholecystitis.  The patient required provision of intravenous antibiotics to treat the acute infectious/inflammatory condition, surgery as performed on day two, and continued post-surgical antibiotics.  The records support timely, expeditious, and medically appropriate care.  While the early post-surgical recovery was uncomplicated, the patient did require ongoing provision of intravenous antibiotics for the biliary infection.  

In this case there is documentation of severity of disease, an anticipated length of stay greater than observation level of care, and provision of intravenous antibiotics for an acute infectious condition that required inpatient admission.  This patient's care spanned a period of greater than standard observation level of care and there is clinical and pathological confirmation of the diagnosis of acute cholecystitis.

General guidelines support that inpatient care is indicated when there is right upper quadrant pain, AND systemic signs of inflammation (fever, C-reactive protein greater than ten, white blood cell (WBC) count greater than ten thousand).  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, the patient had acute cholecystitis and required intravenous antibiotics and acute surgical management to justify an inpatient level of care.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
No, the health plan did not act reasonably with sound medical judgment with its determination in this case.  The submitted medical records and generally accepted clinical guidelines support that the health plan's determination should be overturned in whole in this case.