Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cholecystitis.

Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is overturned.

This case involves an adult patient who presented to the emergency room with complaints of hematuria. The triage notes noted the patient had an elevated temperature at 100.5 degrees Fahrenheit with a heart rate of 97 and blood pressure normal at 123/75. The patient endorsed pain rated 6/10 (scale of 0 to 10) in severity and was noted to have allergies to amoxicillin and penicillin. The patient claimed to have had 5 episodes of hematuria or yellow urine with clots. Reported chest/epigastric pain, chills and had a flat affect. Laboratory values showed elevated glucose at 112, creatinine kinase at the low end of normal of 30, and with liver function studies showing some abnormalities with aspirate transaminase at 275 and alanine aminotransferase at 260. The patient's urinalysis had slightly cloudy clarity with urine specific gravity elevated at 1.033, a large amount of blood, a small amount of leukocyte esterase, with elevated white blood cell count at 44, blood cell count was elevated at 767, epithelial cells at the high end of normal at 5, with evidence of bacteria at 90.6. A Computed Tomography of the chest/abdomen/pelvis was concerning for cholecystitis. The radiology result interpretation was indicated as cholecystitis and urinary tract infection. Records stated the patient was aggressive, verbally abusive, refusing care, assessment, and refusing to answer questions. The patient was cursing at the registered nurse and requesting Against Medical Advice (AMA) papers. Ciprofloxacin 500 milligrams (mg) oral tablets was prescribed. The patient agreed to stay for 24 hours to receive intravenous antibiotics. Following stabilization in the emergency department, the patient was admitted to inpatient for further evaluation and treatment of acute cholecystitis. The patient left AMA and the medical doctor was notified. 

Milliman Care Guidelines state that admission to inpatient care is indicated for patients with acute cholecystitis, when they have one or more the following including fever, elevated C-reactive protein greater than 1 mg per Deciliter, or elevated white blood cell count greater than 10,000. For patients with a urinary tract infection, inpatient admission may be indicated for those individuals who have 1 or more the following including hemodynamic instability, altered mental status that is severe or persistent, persistent or worsening of clinical findings despite observation care, for kidney transplant recipients with suspected pyelonephritis, when the individual has significant uropathy, suspected infection of an indwelling prosthetic device, set, implant, or graft, when there is ureteral obstruction, bladder emptying significantly impaired, renal or perinephric abscess, emphysematous polynephritis or cystitis, hydronephrosis, acute renal failure (stage III acute kidney injury), acute kidney injury (stage II), or a need for intravenous hydration support despite observation care. 

Based upon the provided information, the patient was showing signs of an infection with an elevated temperature while in triage. There were also abnormal laboratory values and imaging findings indicating cystitis and cholecystitis. Given this information, the inpatient admission was appropriate and within the standard of care. While the patient left AMA, it was determined that the provided information was sufficient and supporting the inpatient admission for short-term basis. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient admission is substantiated.