Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal pain

Treatment is an inpatient admission 

The insurer denied coverage for an inpatient admission 
 
The denial is overturned

This is the case of a patient with PMHX (primary medical history) of HTN (hypertension), HDL (hyperlipidemia), and pulmonary HTN (hypertension) who presented to the ED (emergency department) with complaints of a one-day history of abdominal pain. The patient reported her BP (blood pressure) was elevated at home 186/80 with associated left sided chest pain and back pain and abdominal pain. She treated herself with 2 doses of losartan and came to the ED for evaluation. On exam she was afebrile with BP of 186/90 and pulse 73. She appeared ill but nontoxic or diaphoretic. Her rate and rhythm were regular. There was abdominal tenderness without guarding. ED orders included cardiac monitoring, EKG (electrocardiogram), IV (intravenous line), lab work. An EKG without acute ST (interval on a ECG) elevations was noted and was not consistent with an acute STEMI (ST elevated myocardial infarction). A repeat EKG showed the same. ED orders included CT (computed tomography) of the head, CT Angio (angiogram) of the chest, and abdomen/pelvis because of concern for an acute process such as aortic dissection. The CT of the head showed no acute intracranial process. The CT Angio was negative. The CT of the abdomen showed gallstones with wall thickening and pericholecystic fluid consistent with cholecystitis. General surgery agreed with placement in observation under surgery. The ED provider was informed that troponin was elevated at 0.21. 

Based upon the records I do feel that the inpatient admission was justified as this patient could not have been managed as noted by the insurer in an ambulatory/observation setting as she presented with chest pain and elevated troponins. It was only after she was cleared by cardiology could she undergo safely a lap cholecystectomy. Thus, she needed the inpatient admission.
 
According to the guidelines of  MCG (Milliman Care Guidelines) Health Inpatient and Surgical Care- 26th edition Gall bladder or bile duct inflammation or stone ORG: M-555 (ISC) the  clinical indications for admission to inpatient care may include patients with 1 or more of the following:  Acute cholangitis as indicated by ALL of the following: Systemic signs of inflammation indicated by 1 or more of the following: Fever, C-reactive protein level greater than 10 mg (milligrams) /L (liters), White blood cell count greater than 10,000/mm (millimeters) 3 (10 x109/L) or less than 4000/mm3 (4 x109/L);  Evidence of common bile duct disease indicated by 1 or more of the following: Total serum bilirubin level greater than or equal to 2 mg/dL (34 micromoles/L), Liver function test (alkaline phosphatase (ALP), r-glutamyl transferase (GGT), aspartate aminotransferase (AST), or alanine aminotransferase (ALT)) greater than 1.5 times the upper limit of normal, Hepatobiliary imaging showing biliary dilatation or evidence of etiology (e.g., stricture, stone, previously placed stent); Acute cholecystitis as indicated by ALL of the following: Right upper quadrant pain, mass, or tenderness; Systemic signs of inflammation indicated by 1 or more of the following: Fever, C-reactive protein level greater than 10 mg/L, White blood cell count greater than 10,000/mm3 (10 x109/L) or less than 4000/mm3 (4 x109/L) and Cholecystectomy not anticipated (i.e., not during current hospital stay) due to 1 or more of the following: High surgical risk (e.g., severe comorbidities, organ failure), Interval cholecystectomy planned (i.e., not during current hospitalization); Calculus or obstruction of gallbladder or bile duct and 1 or more of the following: Hemodynamic instability, Common bile duct obstruction diagnosed (e.g., by imaging), Vomiting that is severe or persistent, Dehydration that is severe or persistent,  Severe pain requiring acute inpatient management, or Bacteremia. This patient did need to be admitted as she could not have been managed with an outpatient/ ambulatory basis with observation as she had elevated troponins. In fact, the provider decided to wait an extra day after she was cleared because of the elevated troponins. The provider was doing the prudent course in this case since to operate on this patient in the setting of a potential acute coronary syndrome could have been catastrophic. It was only after the patient was cleared for this that he was able to safely perform a lap cholecystectomy. And although according to MCG Inpatient and Surgical Care 26th Edition cholecystectomy by laparoscopy the operative status criteria is ambulatory, in this case the patient required inpatient stay because of the chest pain and elevated troponins. Thus, ambulatory status would not have been appropriate.

Finally, MCG General recovery care 26th edition Ambulatory surgery exception criteria GRG:CG-AEC (ISC GRG) notes that potentially ambulatory procedure or surgery warrants inpatient care due to 1 or more of the following: Inpatient care needed for clinically significant preoperative disease or condition; Complex surgical approach or situation anticipated; Procedure is not low risk and patient at high anesthetic risk; Presence of drug-related risk; Inadequate outpatient care situation; Postoperative event, condition, or finding that warrants inpatient stay. Given the above, the patient did warrant inpatient status as there was a concern for a clinically significant preop disease in the form of an acute coronary syndrome. Thus, inpatient admission was warranted.

Finally, I am knowledgeable in this condition and the recommended health care services provided through actual clinical experience for this condition and therefore feel that the inpatient admission was justified at the inpatient admission level as the patient should not have been managed in an ambulatory/observation setting given the chest pain, marked HTN, and concern for an acute coronary syndrome in the setting of cholecystitis. I do believe that based upon these findings the health care plan did not act reasonably and with sound medical judgment. The criteria I have utilized included my own personal experience as to what constituted good acceptable standard of care, as well as the MCG guideline as noted. The denial is REVERSED.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the inpatient hospital admission is overturned. Medical Necessity is substantiated.