Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal/Abdominal/Stomach Pain.
Treatment: Full Hospital Admission.
The health plan denied the requested full hospital admission as not medically necessary. The health plan's determination is upheld.

The patient is a previously healthy woman who presented to the emergency department (ED) with abdominal pain and vomiting of 8-hours duration. At the time of presentation, the patient was without fever and vital signs were normal. She was tender in the right upper quadrant. The white blood cell (WBC) count was 11.2. The complete metabolic panel identified normal liver enzymes and normal bilirubin. An abdominal ultrasound showed gallstones within the gallbladder and gallbladder wall thickening. The common duct was of normal caliber. She was admitted to the hospital with the diagnosis of cholecystitis.

The patient was evaluated with surgery consultation. The progress note states that cholecystectomy was planned. The patient underwent a laparoscopic cholecystectomy. The gallbladder was tensely distended. It was aspirated to allow for retraction. The operation was performed without complication. The diet was advanced following surgery and pain was controlled with oral medications. The patient remained clinically stable and was discharged from the inpatient setting with planned short term follow up.

At issue is the medical necessity for the full hospital admission.

The health plan's determination of medical necessity is upheld, in whole. An inpatient level of care was not medically necessary in this case.

An alternate level of care would have permitted for the surgical assessment, the surgical procedure and perioperative intravenous (IV) fluid, IV antibiotics, IV antiemetics, and peri-operative 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.

Milliman Care Guidelines (MCG) 26th ed Cholecystectomy by Laparoscopy (referenced in the health plan letter) state that the goal length of stay is observation, but that extended stay or inpatient care may be needed when there is:
1 - Acute cholangitis with systemic signs of sepsis and evidence of common bile duct disease with bilirubin greater than 2 milligrams/deciliter (mg/dl) or aspartate aminotransferase (AST) / alanine aminotransferase (ALT) 1.5 times upper limit of normal, or imaging showing biliary dilatation or evidence of etiology.
2 - Acute cholecystitis (right upper quadrant pain or tenderness, systemic signs of inflammation, cholecystectomy not anticipated due to high surgical risk or plan for interval cholecystectomy).
3 - Also, criteria for inpatient admission may include:
- Failure to achieve discharge criteria.
- Conversion to open surgery.
- Severe post-operative infection.
- Care for active comorbidities.
- Complications of procedure.
- Gallstone ileus.
In this case, the patient presented with an acute onset of upper abdominal pain. She responded favorably to initial treatment with antibiotics and surgical therapy and was stable for discharge from the hospital on the first day following surgery. The above MCG criteria did not exist in this case to warrant an inpatient level of care. The care provided could have appropriately been rendered with an alternate level of care for this patient.