Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest Pain
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient hospital admission.
The denial is overturned.

The patient is an adult female who presented to the Emergency Department (ED) with chest pain. Past medical history included gastroesophageal reflux disease (GERD) and arthritis. At the time of presentation, the patient was without fever and vital signs identified tachycardia (116 beats per minute). White blood cell count was normal at 8.9 thousand. The complete metabolic panel revealed slight elevation of alkaline phosphatase with normal liver enzymes and normal bilirubin. Abdominal ultrasound and computed tomography (CT) scan showed gallstones within the gallbladder and gallbladder wall thickening. The common bile duct was nine millimeters in diameter. The patient was admitted to the hospital with the diagnosis of cholecystitis.

The patient was evaluated with surgery consultation the next day. She was evaluated with magnetic resonance cholangiopancreatography (MRCP) that showed a distended gallbladder with large stones, wall thickening, and pericholecystic fluid. There were no common duct stones. Gastroenterology consultation was obtained on day # (number) 2. Follow-up lab data on day #3 showed normalization of the alkaline phosphatase. The patient underwent laparoscopic (robotic assisted) cholecystectomy. The operative note describes an acutely inflamed gallbladder with stones and purulent fluid in the gallbladder. The operation was performed without complication. On day #4, the patient reported poorly controlled pain. Vital signs were normal. The diet was advanced following surgery. Antibiotics were continued on day #4 through day #6. On day #5, the patient was without new complaint, vital signs were normal, and pain management was with oral medications. The patient remained clinically stable and was discharged from the inpatient setting on day #6 with planned short-term follow-up.

The health plan denial letter states that there is no documentation of unstable vital signs or fever, signs of infection, stone or blockage of the bile duct, or jaundice. The denial 
of inpatient admission was based on Milliman Care Guidelines Gallbladder or Bile Duct Inflammation or Stone.

The proposed treatment was medically necessary.

This patient presented to the hospital ED as a transfer patient with chest pain. She was determined to have acute cholecystitis. She had elevation of serum alkaline phosphatase that prompted additional diagnostic work up on the next day. The patient was found to have acute cholecystitis at the time of surgery on day #3 with empyema of the gallbladder. This was confirmed by the pathology report that documents a gangrenous gallbladder. Additionally, there is documentation of failure to achieve discharge criteria as the patient had poorly controlled post-surgical pain as detailed in the day #4 progress note and required provision of intravenous antibiotics for the acute biliary infection.

Acute inpatient care was medically necessary for this patient as the care and treatment provided spanned a period of greater than 48 hours and could not have been rendered with a lower level of care. A lower level of care would not have provided for ED assessment, surgical assessment, gastrointestinal consultation, additional imaging, laparoscopic cholecystectomy as performed on day #3, provision of intravenous antibiotics, and continuation of post-surgical antibiotics based on operative findings in this case. An inpatient level of care was medically necessary in this case.