Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal Pain
Treatment: Inpatient Admission
The insurer denied: Inpatient Admission
The denial is: Overturned

The patient is a male who presented to the emergency department (ED) on with abdominal pain of several days duration. He had previously been evaluated at another hospital and found to have gallstones. At the time of presentation, the patient was without fever and vital signs identified normal heart rate and blood pressure. He was tender in the right upper quadrant. The white blood cell (WBC) count was elevated at 20 thousand (K). The complete metabolic panel identified normal liver enzymes and normal bilirubin. Ultrasound and computed tomography (CT) scan showed gallstones and gallbladder wall thickening.
He was admitted to the hospital and initially treated with intravenous (IV) fluid, antibiotics, and antiemetics. Surgery consultation was obtained. An infectious disease consultation was obtained. This note states that the patient wanted to leave the hospital against medical advice (AMA). This note also states that he was not currently a candidate for intervention and IV antibiotics were prescribed. He refused to sign the AMA paperwork.
The subject under review is the medical necessity for the inpatient admission.

The health plan's determination is overturned.

The requested inpatient admission was medically necessary. This patient presented to the ED with abdominal pain of several days duration. He had a markedly elevated WBC count of 20 K and imaging confirmation of acute cholecystitis per ultrasound and CT scan.
He was appropriately started on IV antibiotics with plans for provision of parenteral antibiotics and deferral of surgical therapy until after the acute episode resolved. However, the patient left the hospital AMA. While the patient decided to leave the hospital against medical advice prior to completion of the prescribed therapy, this does not obviate the clinical appropriateness of the decision to admit this patient to an inpatient level of care. During this time the patient received the coordinated care of the infectious disease service and the surgical service, he was treated with parenteral antibiotics and monitored with lab data and nursing care.
The submitted records do not support that the patient was in the hospital after leaving AMA.
Milliman Care Guidelines (MCG) state that while the goal length of stay is observation for cholecystectomy, extended stay or inpatient care may be needed when there is:
Acute cholangitis with systemic signs of sepsis and evidence of common bile duct disease with bilirubin greater than (>) than 2 milligrams per 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
Acute cholecystitis (right upper quadrant [RUQ] pain or tenderness, systemic signs of inflammation, Cholecystectomy not anticipated due to high surgical risk or plan for interval cholecystectomy)
In this case, the patient had acute cholecystitis and cholecystectomy was not anticipated due to high surgical risk with plan for interval cholecystectomy. Therefore, an inpatient level of care was appropriate.