Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Status post Surgery
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld.

The patient is a man who presented to the Emergency Department with abdominal pain and vomiting of one day duration.  At the time of presentation the patient was without fever and vital signs were normal.  He was tender in the right upper quadrant.  The WBC (white blood cells) count was elevated at 12.4 K (thousand).  The complete metabolic panel identified elevated bilirubin (1.7).  Abdominal ultrasound showed gallstones within the gallbladder and a 4-mm thick gallbladder wall.
The patient was in the emergency department overnight and was evaluated with surgery consultation.  Magnetic resonance cholangiopancreatography was ordered, but subsequently cancelled due to normalization of bilirubin.  The patient underwent laparoscopic cholecystectomy.  The operation was performed without complication.  The diet was advanced and pain was controlled.  The patient remained clinically stable and was discharged from the inpatient setting with planned short term follow up.

This patient is a man who presented to the hospital with abdominal pain and vomiting.  He was determined to have cholelithiasis/cholcystitis/biliary colic.  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, or any other condition requiring inpatient admission.  The indication for cholecystectomy was established.  The patient was in the emergency department.  He did not undergo surgery to remove the gallbladder until day three.  The patient responded favorably to treatment and was stable for discharge from the hospital with planned follow up.  Acute inpatient care was not medically necessary for this patient as the care and treatment provided could have been rendered with a lower level of care.  A lower level of care would have provided for ED (emergency department) assessment, surgical assessment and monitoring, provision of IV (intravenous) antibiotics and fluid, and overnight care.

Inpatient level of care was not medically necessary.  A lower level of care would have permitted for the surgical assessment, the surgical procedure and perioperative intravenous fluid, intravenous antibiotics, intravenous antiemetics, and overnight monitoring.  The submitted records document that this patient was clinically and hemodynamically stable at the time of presentation.  The patient was clinically stable throughout the period of monitoring as supported by the corresponding medical records.  While the bilirubin was initially elevated, it promptly normalized and did not require further evaluation.

Inpatient care may be indicated when there is right upper quadrant pain, and systemic signs of inflammation (fever, C-reactive protein > [greater than] 10, white blood cells count > [greater than] 10 K).  Inpatient admission may also be 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 white blood cells count and bilirubin promptly normalized, the indication for cholecystectomy was established, but the patient did not undergo cholecystectomy until day three.  None of these indications for an inpatient designation existed to justify an inpatient level of care.