Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Inpatient Hospital. 
The insurer denied Inpatient Admission. 
The denial is overturned. 

The patient is a male who presented to the emergency department (ED) with severe and worsening abdominal pain of several days duration. At the time of presentation, the patient was without fever and vital signs were notable for hypertension with a blood pressure of 145/92 millimeters of mercury (mmHg). The heart rate was elevated at 105/minute. He was tender in the epigastrium and right upper quadrant. The white blood cell (WBC) count was elevated at 14.6. The complete metabolic panel identified normal bilirubin and serum transaminases. Ultrasound showed gallbladder thickening, gallstones, and pericholecystic fluid.
He was admitted to the hospital and initially treated with intravenous (IV) fluid, antibiotics, and antiemetics. Surgery consultation was obtained. He was treated with laparoscopic cholecystectomy with cholangiogram. The operative dictation and the anesthetic record described a markedly thickened and inflamed gallbladder. The procedure was completed without complication, but a surgical drain was placed due to the severity of the inflammation. The patient was treated with post-surgical monitoring, IV fluid, IV analgesia, and antiemetics. The immediate post-surgical recovery was uncomplicated.
The drain had put out 80 cubic centimeters (cc) of serosanguinous fluid and the WBC count had decreased to 11.7. He was continued on IV antibiotics. The drain was removed. He was stable from the standpoint of the surgical service, and he was discharged from the inpatient setting.
At issue is the medical necessity of the Inpatient Admission.

The health plan's determination of medical necessity is overturned in whole.

The requested health service/treatment of Inpatient Admission was medically necessary for this patient. 
Inpatient care was medically necessary for this patient. The patient presented with acute cholecystitis and an elevated WBC count. He required IV antibiotics. He did undergo the surgical procedure in a timely manner and was found to have acute cholecystitis that necessitated placement of a surgical drain. He required additional provision of IV antibiotics following surgery. An inpatient level of care was required for the pre-surgical assessment, the surgical procedure and perioperative IV fluid, IV antibiotics, IV antiemetics, and post-surgical monitoring and drain management. 
General guidelines support that inpatient care is indicated when there is right upper quadrant pain, and systemic signs of inflammation (fever, C-reactive protein [CRP] greater than [>] 10, WBC count > 10). Inpatient admission is also 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, the patient had acute cholecystitis and required IV antibiotics and acute surgical management to justify an inpatient level of care.
Therefore, the requested health service/treatment of Inpatient Admission was medically necessary.