Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain and vomiting.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a previously healthy male who presented to the emergency department (ED) with abdominal pain and vomiting of three days duration. At the time of presentation, the patient was without fever and vital signs were normal. He was tender in the right upper quadrant. The white blood cell (WBC) count was normal at 6.4 thousand (K). The complete metabolic panel identified elevated aspartate aminotransferase (AST) and alanine aminotransferase (ALT) with normal bilirubin.  Abdominal ultrasound showed sludge within the gallbladder and a sonographic Murphy's sign.  

The patient was admitted to the hospital and initially treated with intravenous (IV) fluid, antibiotics, and antiemetics. Surgery consultation was obtained. Hepatobiliary iminodiacetic acid (HIDA) scan was performed and was normal. He was started on a diet, but did not tolerate oral intake. The patient underwent laparoscopic cholecystectomy and umbilical hernia repair. The operation was performed without complication. The diet was advanced and pain was controlled. The patient remained clinically stable and was discharged from the inpatient setting with planned short term follow up.

No, the proposed inpatient hospital admission was not medically necessary.

An inpatient level of care was not medically necessary in this case. This patient is a male who presented to the hospital with abdominal pain and vomiting. He was determined to have cholelithiasis/biliary colic. There is no documentation of a 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, or any other condition requiring inpatient admission.  

The indication for cholecystectomy was established. The patient did not undergo surgery to remove the gallbladder until day three. The patient responded favorably to treatment and was stable for discharge from the hospital on day four with planned follow up. Acute inpatient care was not medically necessary for this patient as the care and treatment provided could have been rendered with a lower level of care. A lower level of care would have provided for emergency room (ED) assessment, surgical assessment and monitoring, provision of intravenous antibiotics and fluid, and overnight care.

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
The health plan acted reasonably. Inpatient level of care was not medically necessary.  A lower level of care would have permitted for the surgical assessment, the surgical procedure and perioperative intravenous fluid, intravenous antibiotics, intravenous antiemetics, and overnight monitoring. The submitted records document that this patient was clinically and hemodynamically stable at the time of presentation.  The patient was clinically stable throughout the period of monitoring 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 ten, white blood cell count (WBC) count greater than ten 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.