Appeal type: Medical necessity
Decision: Upheld

Digestive System/ Gastrointestinal/Other/Choledocholithiasis, Epigastric Pain
Inpatient Hospital/Inpatient emergency admission. 
The health plan has denied the requested service, inpatient emergency admission, as not medically necessary. The health plan's determination is upheld.

The patient presented to the emergency department with abdominal pain. The patient had associated nausea and vomiting. On examination, the patient had right upper quadrant and epigastric tenderness with positive Murphy sign. Laboratory studies demonstrated a white blood cell count (WBC) of 10.4 and a platelet count of 438. The patient's aspartate aminotransferase (AST) and alanine aminotransferase (ALT) were elevated. An ultrasound of the abdomen demonstrated cholelithiasis with sonographic Murphy sign. These findings were interpreted as indeterminate for acute cholecystitis. The patient was hospitalized. The patient underwent a magnetic resonance cholangiopancreatography (MRCP) with demonstration of cholelithiasis with gallbladder wall edema and pericholecystic fluid concerning for cholecystitis in the appropriate clinical setting. Later that day, the patient underwent a laparoscopic cholecystectomy. A single stone was identified in the common bile duct and was flushed into the duodenum after glucagon administration. Later that day, the patient met discharge criteria and was discharged home.

At issue is the medical necessity for an inpatient emergency admission.
The health plan's determination of medical necessity should be upheld, in whole.

The patient's admission was not medically necessary at the inpatient level of care for the entire admission.

Per the Milliman Care Guidelines (MCG) inpatient admission is indicated for acute cholangitis, acute cholecystitis when cholecystectomy is not anticipated, and for calculous or obstruction of the gallbladder with certain complications. The patient does not meet criteria for acute cholangitis, as this requires systemic signs of inflammation and evidence of common bile duct disease. The patient does not meet criteria for acute cholecystitis with signs of systemic inflammation or where cholecystectomy was not anticipated. The patient did not have a fever, C-reactive protein elevation, or white blood cell count elevation. The patient does not meet criteria for calculous, obstruction of the gallbladder, bile duct with hemodynamic instability, common bile duct obstruction, vomiting that was severe or persistent, severe pain requiring acute inpatient management, or bacteremia. The patient also did not meet MCG criteria for undiagnosed abdominal pain which requires: hemodynamic instability, severe pain, peritoneal signs, identification of an etiology that requires inpatient care, nothing by mouth (NPO) status greater than (>) 24 hours requiring significant intravenous (IV) fluid support, suspected toxic megacolon, bacteremia, a procedure that cannot be performed on ambulatory basis, or parenteral nutrition. The documentation does not suggest that the patient's care could not have been performed at a lower level care. There is no evidence that additional complex testing or therapy other than the procedure was performed. There is no documentation that the treating team identified conditions or problems specific to the patient that would have required inpatient care. The provided documentation does not support the medical necessity of an inpatient level of care.