Appeal type: Medical necessity
Decision: Overturned

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

The patient is a woman. She who presented to the hospital ED (emergency department) with abdominal pain, vomiting, and diarrhea of one week duration. Her comorbid health conditions included obesity (BMI [body mass index] 33.9). 

At the time of presentation, the patient was without fever, and vital signs showed a normal heart rate and blood pressure. She was tender in the right upper abdomen. The WBC (white blood cell) count was 6.4 K (thousand). The complete metabolic panel identified elevated serum transaminases, bilirubin and alkaline phosphatase. Abdominal ultrasound showed gallstones. The common bile duct was 6-7-mm (millimeters) in size. She was initially treated with IV (intravenous) fluid, pain medications and antiemetics. She was admitted to the hospital. MRCP (Magnetic Resonance Cholangiopancreatogram) was performed showing gallstones, but no common bile duct (CBD) stones. Internal medicine, surgery and gastroenterology consultations were obtained. She was to be monitored with serial lab data and the recommendation was for laparoscopic cholecystectomy. 

The patient remained clinically stable during the period of monitoring but decided to leave the hospital against medical advice without further treatment. 

The health plan letter references MCG (Milliman Care Guidelines) 24th edition Gallbladder or bile duct inflammation or stone. The health plan letter states that hospital admission was not medically necessary, as there was no serious problems such as fever, jaundice, bowel blockage, persistent vomiting, or severe pain that required inpatient stay. 

Yes, the Inpatient admission was medically necessary. 

This patient is a woman who presented to the hospital with cholelithiasis/cholecystitis and elevated liver enzymes. The patient was clinically stable at the time of presentation, but did have lab abnormalities of elevated AST (aspartate aminotransferase), ALT (alanine aminotransferase), alkaline phosphatase and bilirubin. It would have been reasonable to anticipate a length of stay of greater than 48-hours, but the patient declined definitive treatment and left the hospital against medical advice. 

The care and treatment provided during this time required an intensity of service consistent with inpatient status, and the anticipated length of stay was reasonably expected to last more than 48-hours. An inpatient level of care would have most appropriately provided for ED (emergency department) assessment, surgical, internal medicine, and gastroenterology assessment, imaging with ultrasound and MRCP (Magnetic Resonance Cholangiopancreatogram), serial lab monitoring, provision of IV (intravenous) fluid and medication, and overnight care. 

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient. 

Based on the submitted clinical documentation, an inpatient level of care was medically necessary during this time. This patient was admitted to the hospital with the diagnosis of cholelithiasis/cholecystitis. The plan was to monitor the patient with serial lab data to follow the elevated liver enzymes in anticipation of cholecystectomy. However, the patient left the hospital against medical advice prior to definitive treatment (laparoscopic cholecystectomy). There were no complications or other clinical issues that manifested during this period of monitoring. However, the intensity of service was consistent with inpatient status, and the anticipated length of stay was reasonably expected to last more than 48-hours. 

An inpatient status would have most appropriately provided for the surgical, medical and GI (gastroenterology) consultations, IV (intravenous) fluid, IV (intravenous) antibiotics, IV (intravenous) antiemetics, and imaging/lab data that was obtained. 

The referenced MCG (Milliman Care Guidelines) state that inpatient care is indicated when there is right upper quadrant pain, and systemic signs of inflammation (fever, C-reactive protein > 10, WBC [white blood cell] count > 10 K [thousand]). 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 lab abnormalities consistent with common bile duct obstruction, and this did justify an inpatient level of care.