Appeal type: Medical necessity
Decision: Upheld

Diagnosis: right upper quadrant abdominal pain

Treatment: inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld. 

This is an adult female who presented to the emergency room (ED) complaining of 1-week right upper quadrant (RUQ) abdominal pain. She was afebrile with stable vital signs. She denied nausea, vomiting, or fever. Examination revealed tenderness in the right upper quadrant (RUQ) without guarding or rebound. Ultrasound showed a stone in the gallbladder neck. The assessment was biliary colic. Sonogram of the abdomen revealed echogenic gall bladder with sludge and stones present in the neck of the gallbladder. There was no evidence of gall bladder wall thickening or peri cholecystic fluid. The common bile duct (CBD) was not dilated. Computerized tomography (CT) of the abdomen revealed unremarkable gall bladder and biliary tree. The plan was to admit to surgery.

The white blood cell (WBC) count was 6.59. Liver function tests (LFT) were normal. The plan was Nil Per Oral (NPO). Ultrasound and Computerized tomography (CT) were reviewed. The plan was possible surgery the following Monday (two days) given lack of operating room (OR) availability. The patient was allowed a low-fat diet as tolerated, and if tolerating oral intake and desires to be discharged for further elective follow up, patient may be discharged.
 
Progress notes the following day indicated the patient was doing well with working diagnosis of biliary colic. She was afebrile. She was tolerating diet. The plan was for laparoscopic cholecystectomy.

Progress notes on operative day indicated the pain was controlled and no acute events overnight. The patient underwent an uneventful robotic laparoscopic cholecystectomy.  Post-operative note indicated the patient can resume low fat diet. For possible discharge in the morning.

The patient had a procedure with no complications during the procedure or after the procedure that would require acute inpatient care. Specifically an inpatient admission was denied as not medically necessary because the patient did not have the following: a potentially ambulatory procedure or surgery that warranted inpatient care due to one or more of the following: inpatient care needed for clinically significant preop disease or condition, as indicated by 1 or more of the following: severe infection, altered mental status, dangerous arrhythmia, hypotension, hypoxemia, other serious condition or finding that required preop inpatient care; complex surgical approach or situation anticipated  as indicated by 1 or more of the following: unusually difficult procedure, prolonged airway monitoring required, other aspect or feature of procedure that indicated a need for longer than usual postop care. 

According to the guidelines of Milliman Care Guidelines (MCG) Health Inpatient and Surgical Care- 27th edition Gall bladder or bile duct inflammation or stone ORG: M-555 patients may be discharged to a lower level of care (either later than or sooner than the goal) when it is appropriate for their clinical status and care needs. 

According to Milliman Care Guidelines (MCG) Inpatient and Surgical Care 27th Edition cholecystectomy by laparoscopy the operative status criteria is ambulatory. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for inpatient hospital stay is not substantiated.