Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain - cholelithiasis/cholecystitis.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient presented to the emergency department (ED) with right sided abdominal pain, nausea and vomiting of 3-days duration. He has a history of hypertension, coronary artery disease, and diabetes. At the time of presentation, the patient was without a fever and the heart rate was 100 beats per minute. He had a tender abdomen per the examination. The white blood cell (WBC) count was normal at 7.0 thousand (K). The complete metabolic panel showed elevated bilirubin and elevated transaminases. An abdominal ultrasound showed gallstones and a dilated gallbladder. The vital signs were normal. The abdomen was reported to be non-tender. A computed tomography (CT) scan was obtained and showed a large gallstone in the neck of the gallbladder. The records indicate that the bilirubin level did decrease on a follow up lab study. The progress notes and discharge summary state that a cholecystectomy was not immediately planned. He was treated with antibiotics with clinical improvement.
The patient remained clinically stable and was discharged from the inpatient setting with instructions for outpatient follow up for an elective cholecystectomy.
At issue is the medical necessity of an inpatient stay.

An inpatient stay was not medically necessary in this case. This patient presented to the hospital with abdominal pain. The records and the diagnostic work up support the diagnosis of cholelithiasis/cholecystitis and this diagnosis was established. There is no documentation of hemodynamic, pulmonary, neurological, or metabolic reason for an acute inpatient level of care. Additionally, there is no documentation of failure to achieve discharge criteria, care for comorbidities, procedural complications, or any other condition requiring inpatient admission. 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 which would have provided for emergency department (ED) assessment, surgical consultation, monitoring, provision of antibiotics and fluid, and overnight care.
The patient was treated non-operatively during this admission with planned outpatient follow up. There were no hospital complications or other clinical issues that mandated an inpatient designation. He remained stable and was discharged from the hospital.
He was tolerating a full liquid diet and oral analgesia. Inpatient stay may be needed for failure to achieve discharge status criteria, conversion to open surgery, systemic infection, care for active comorbidities, complications of procedure. In this case none of these conditions existed to warrant an inpatient level of care. 
Inpatient admission may 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.