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 woman. She presented to the ED (emergency department)  with worsening abdominal pain. She had been seen in the ED (emergency department) the day prior and was diagnosed with cholelithiasis and was subsequently discharged.

At the time of presentation the patient was without fever and vital signs were normal. She was tender in the right upper quadrant. The WBC (white blood cell) count was normal at 8.4 K (thousand). The complete metabolic panel was without findings of biliary obstruction. Abdominal ultrasound showed gallstones with borderline gallbladder wall thickening.

The patient was admitted to the hospital and initially treated with IV (intravenous) fluid and antiemetics. Surgery consultation was obtained. She was treated with laparoscopic cholecystectomy the following day. The operation was completed without complication. The patient was treated with post-surgical monitoring, IV (intravenous) fluid, IV (intravenous) analgesia, and antiemetics. The immediate post-surgical recovery was uncomplicated.

The day after the procedure, 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.

No, the Inpatient admission was not medically necessary.
An inpatient level of care was not medically necessary in this case. This patient is a woman 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 the next day without adverse event and the patient was stable for discharge from the hospital. Acute inpatient care was not medically necessary for this patient as the care and treatment provided could have been rendered at a lower level of care setting. A lower level of care would have provided for ED (emergency department) assessment, perioperative care and monitoring, provision of IV (intravenous) antibiotics and fluid, and overnight care during this period of time.

Yes, the health plan did act 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 a lower level of care with subsequent transition to outpatient care. The patient presented to the hospital and was found to have biliary colic/cholecystitis. The diagnosis and indication for surgery was established. She underwent an uncomplicated laparoscopic cholecystectomy procedure. There were no peri-operative complications or other clinical issues. She remained stable and was without complaint. She was discharged from the hospital.

Inpatient level of care was not medically necessary. A lower level of care would have permitted for the pre-surgical assessment, the surgical procedure and perioperative IV (intravenous) fluid, IV (intravenous) antibiotics, IV (intravenous) antiemetics, and post-surgical monitoring. The submitted records document that this patient was clinically and hemodynamically stable at the time of presentation. The WBC (white blood cell) count was normal and serum chemistries were normal at the time of presentation. The patient was clinically stable following surgery as supported by the corresponding medical records.

Inpatient care may be indicated when there is right upper quadrant pain, and systemic signs of inflammation (fever, C-reactive protein > [greater than] 10, WBC [white blood cell] count > [greater than] 10 K [thousand]). 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, none of these indications existed to justify an inpatient level of care.