Appeal type: Medical necessity
Decision: Upheld

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

The patient is a female who presented to the emergency department (ED) with abdominal pain.  At the time of presentation the patient was without fever and vital signs were normal.  She was tender in the right upper quadrant.  The white blood cell (WBC) count was normal at 7.9 thousand (K).  The complete metabolic panel was without findings of biliary obstruction.  Abdominal ultrasound also showed gallstones without gallbladder wall thickening or adjacent fluid.  

The patient was admitted to the hospital and initially treated with intravenous (IV) fluid and antiemetics.  Surgery consultation was obtained and laparoscopic cholecystectomy with cholangiogram was performed same day.  The operative dictation and the anesthetic record describe an acutely inflamed gallbladder. The procedure was completed without complication.  The patient was treated with post-surgical monitoring, intravenous (IV) fluid, intravenous (IV) analgesia, and antiemetics.  The immediate post-surgical recovery was uncomplicated.  Day two, the patient had normal vital signs and had no complaints.  She was tolerating a liquid diet.  Pain was controlled.  The diet was advanced.  The patient remained clinically stable and was discharged from the inpatient setting on day two.

No, the proposed treatment was not medically necessary.
An inpatient level of care was not medically necessary in this case.  This patient is a female who presented to the hospital with abdominal pain.  She was determined to have cholelithiasis/cholecystitis.  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, procedural complications, or any other condition requiring inpatient admission.  The indication for cholecystectomy was established.  Surgery was performed and the patient was stable for discharge from the hospital on day two.  Acute inpatient care was not medically necessary for this patient as the care and treatment provided could have been rendered in the observation setting.  An observation level of care would have provided for ED assessment, perioperative care and monitoring, provision of IV antibiotics and fluid, and overnight care.

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
There is no compelling reason why this patient could not have safely and appropriately been treated at the observation level of care with subsequent transition to outpatient care.  The patient presented to the hospital and was found to have biliary colic/cholecystitis.  She underwent an uncomplicated laparoscopic cholecystectomy procedure.  There were no peri-operative complications or other clinical issues.  She remained stable and was discharged from the hospital on the first post-surgical day.  

Inpatient level of care was not medically necessary.  An observation level of care would have permitted for the pre-surgical assessment, the surgical procedure and perioperative intravenous (IV) fluid, intravenous (IV) antibiotics, intravenous (IV) antiemetics, and post-surgical monitoring.  The submitted records document that this patient was clinically and hemodynamically stable at the time of presentation.  The patient was clinically stable following surgery as supported by the corresponding medical records.

The referenced Milliman Care Guidelines (MCG) 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, none of these indications existed to justify an inpatient level of care.