Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Biliary colic versus acute cholecystitis. 

Treatment: Inpatient admission. 

The insurer denied coverage for the inpatient admission. 

The denial is upheld. 

This is an adult female patient with a past medical history of diabetes, hypertension, high cholesterol, hyperthyroidism, irritable bowel syndrome and polyneuropathy. She presented to the hospital from her primary physician's office with complaints of abdominal pain in the right upper quadrant. She was also complaining of having pleuritic chest pains. The patient reported that the pain was 10/10 and radiated to her back and right shoulder and that she had some nausea but no vomiting. In the hospital her vital signs were temperature- 98, heart rate- 88, respiratory rate- 20, blood pressure- 133/58, and oxygen (O2) saturation level was 100 % on room air. The patient was in no apparent distress (NAD). Her lungs were clear. Cardiovascular assessment noted first heart sound (S1) and second heart sound (S2) was normal. She was experiencing right upper quadrant (RUQ) and epigastric pain. There was no cyanosis, clubbing or edema noted. Her laboratory blood work revealed her white blood (WBC) count was 5.8, hemoglobin (Hgb) 12.5, electrolytes were within normal range, and was venous blood gases (VBG) were 7.37/42/59/24. The patient's chest x-ray did not reveal any pathology. 

The patient was treated with intravenous (IV) fluids, IV pain meds, Famotidine, Maalox. Differential diagnosis was biliary colic versus acute cholecystitis. A computed tomography (CT) angiogram was done which revealed questionable small thrombus in sub segmental branch of posterior right lower lobe (RLL) and right sub segmental pulmonary embolism (PE). The patient was admitted to the hospital, she was given Lovenox, and pain medications were continued. Liver function tests (LFTs) were normal. Ultrasound of RUQ did not reveal any gall stones or gallbladder (GB) pathology. Cardiac enzymes and electrocardiogram (EKG) were within normal limits.

The patient remained stable after admission. Myocardial infarction (MI) and GB pathology had been ruled out. She was afebrile and hemodynamically stable and O2 saturation normal on room air.  The patient was tolerating orally. WBC and other labs remained stable. An echocardiogram was done which was essentially normal. No right ventricular (RV) strain or dysfunction. This patient remained stable and was subsequently discharged home on oral pain meds. Her husband also reported that the patient had some history of anxiety and felt that she needed some medications for that as some of her symptoms may be related to it.

This patient did not need acute inpatient hospitalization. She could have been placed in observation status while diagnostic testing and treatment were initiated. She was afebrile and hemodynamically stable throughout. WBC was normal. She was not hypoxic. The patient did not have an MI or GB disease. PE if present was not clinically significant. It was questionable sub segmental. 

This patient could have been discharged home on oral medications if clinically indicated after a period under observation which could have been up to 48 hours.

The health plan acted reasonably, with sound medical judgment and in the best interest of the patient.

The insurer's denial of coverage for the inpatient admission is upheld. Medical necessity is not substantiated.