Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient is an adult female who presented to the Emergency Department with right upper abdominal pain, nausea, and vomiting of two-days duration. Comorbid health conditions included lupus, celiac disease, and Thalassemia minor. At 
the time of presentation, the patient was without fever and vital signs identified a heart rate of 73 beats per minute. Blood pressure was 103/53 millimeters of mercury (mmHg). She was tender in the right upper quadrant. The white blood cell (WBC) count was 8.4 thousand (K). The complete metabolic panel identified normal liver enzymes and normal bilirubin. Ultrasound showed gallstones impacted in the fundus of the gallbladder and a wall thickness of 4 millimeters. The common duct was of normal caliber. The patient was admitted to the hospital and initially treated with intravenous fluid, antibiotics, and antiemetics. The admission diagnosis was that of acute cholecystitis. Surgery consultation was obtained. Rheumatology consultation was requested for management of her lupus medications. 
On day # (number) 2, the patient had persistent abdominal pain. Vital signs were normal. The white blood cell count was 6.9 thousand and liver enzymes remained normal. The surgical plan was for 
consultation with Rheumatology regarding this patient's immunosuppressive medications. On day #3, vital signs were normal. The patient had a non-tender abdomen. The WBC count was normal. Laparoscopic cholecystectomy was planned for day #4. On day #4, the patient underwent cholecystectomy. The records indicate that the procedure was completed without complication. The discharge note on the next day states that the patient was discharged from the hospital with instructions for follow up.

The proposed treatment was not medically necessary.

This patient is an adult female who presented to the Emergency Department with abdominal pain that was attributed to biliary disease. She had imaging confirmation of cholelithiasis on ultrasound. Lab data identified a normal white blood cell (WBC) 
count and normal liver enzymes. The patient was appropriately provided intravenous fluid. Rheumatology consultation was requested. The indication for cholecystectomy was established as presentation. The patient had persistent abdominal discomfort with normal lab data on day #2 and day #3. She ultimately underwent cholecystectomy and was stable for discharge from the hospital on the first post-surgical day. Had surgery been performed on day #2 (rather than on day #4), then it would have been reasonable to conclude that the patient would have been stable for discharge from the hospital on day #3 (rather than on day #5). An inpatient level of care was not consistent with 
nationally accepted medical standards as the care provided could have reasonably been rendered with a lower level of care. 
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 2 milligrams per deciliter (mg/dl) or aspartate aminotransferase/alanine aminotransferase (AST/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, these criteria did not exist to warrant inpatient admission.