Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Inpatient Hospital. 

The insurer denied inpatient stay. 
The denial is overturned. 

This patient is a male (body mass index [BMI] 48 kilograms per square meter [kg/m2]) who presented to the hospital emergency department (ED) with the complaint of worsening abdominal pain and vomiting. Comorbid health conditions included chronic myelogenous leukemia (CML), pleural effusions, hyperlipidemia, and kidney stones. Lab data showed an elevated white blood cell (WBC) count of 14 thousand (K). He was tender in the right abdomen. computed tomography (CT) scan and abdominal ultrasound identified findings consistent with cholecystitis. 

The patient was started on intravenous (IV) fluid, antibiotics, and antiemetics. Cardiology consultation was obtained due to his history of pleural effusions and possible chemotherapy related cardiomyopathy. He underwent laparoscopic cholecystectomy. The operative dictation describes an acutely inflamed and gangrenous gallbladder. He was treated with IV antibiotics in the post-operative period. He also required intravenous diuretic on the first post-surgical day as treatment of volume overload. The next day the patient was started on a diet. The WBC count normalized (8.8 K). His pulmonary status was monitored due to his pre-existing condition of CML and pleural effusions. Once he tolerated a diet, pulmonary status was deemed stable, and pain was controlled with oral medications, he was discharged from the hospital. The subject under review is the medical necessity for the inpatient stay. 

The health plan's determination is overturned. 

Inpatient care was medically necessary because this patient had documentation of acute cholecystitis and significant comorbid health conditions of CML and pleural effusions.
He had upper abdominal pain and tenderness at the time of presentation to the ED and had an elevated WBC count of 14 K. His clinical condition was consistent with acute cholecystitis. He had significant comorbid health conditions of CML and pleural effusions. Imaging data also identified findings consistent with acute cholecystitis. At the time of surgery this diagnosis was confirmed with direct inspection of the gallbladder. During this period of inpatient admission, the patient required provision of IV fluid, IV diuretics, antibiotics, and pain medications. The records indicate that the patient was appropriately cared for over a period of time that spanned greater than (>) 2-nights.
Inpatient care was medically necessary because this patient had documentation of acute cholecystitis. This condition required provision of IV fluid, antibiotics, antiemetics, and prompt surgical intervention. This care and treatment were most appropriately carried out in the inpatient setting as there was need for regular clinical assessment by the treating surgical service, coordination of care with the cardiology service, monitoring of respiratory status and provision of IV diuretics, follow up lab assessment, and provision of parenteral medications that spanned >2-nights for the diagnosis of acute cholecystitis. Milliman Care Guidelines (MCG) also support that inpatient care was appropriate as this patient had acute cholecystitis with upper abdominal pain and tenderness and a WBC count of 14 K . 

The care and treatment were appropriately provided in the inpatient setting due to need for parenteral antibiotics, IV diuretics, coordination of multiple medical and surgical services, and pain management.