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 obese female. She presented to the ED (emergency department) with new onset right upper abdominal pain and nausea of one-week duration. She had been seen 10 days earlier for similar abdominal complaints. At the time of presentation, the patient was without fever and vital signs were normal. She was without abdominal tenderness. The WBC (white blood cell) count was elevated at 12.3 K (thousand). The complete metabolic panel identified elevated liver enzymes and bilirubin. Abdominal ultrasound showed sludge within the gallbladder with no gallbladder wall thickening. The bile duct was of normal caliber. She was admitted to the hospital. 

The patient was evaluated with surgery and gastroenterology consultations. She was started on IV (intravenous) antibiotics. On first day, the bilirubin value was further increased to 2.6. It was the recommendation of the GI (gastroenterology) consultant for cholecystectomy with cholangiogram. If the cholangiogram was positive for ductal stones, then the GI (gastroenterology) department would arrange for post-procedure ERCP (endoscopic retrograde cholangiopancreatography)/stone extraction. 

On the second day, a repeat abdominal ultrasound was requested. The bilirubin value had normalized. The patient underwent laparoscopic cholecystectomy with cholangiogram on the third day (the brief operative note states that a cholangiogram was performed, however, the dictated operative note does not detail performance of the cholangiogram). 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 on the following day with planned short term follow up. The health plan denial letter notes that the denial of an inpatient level of care was based on MCG (Milliman Care Guidelines) 25th edition Gallbladder or Bile Duct Inflammation or Stone. This letter states that an Observation level of care was approved. The denial is being appealed. 

The Inpatient Hospital Admission was not medically necessary. 

An inpatient level of care was not medically necessary in this case. This patient is an adult female who presented to the hospital with abdominal pain. She was determined to have cholelithiasis/cholecystitis. There is no documentation of hemodynamic, pulmonary, neurological, or metabolic reason for an acute inpatient level of care. Additionally, there is no documentation of failure to achieve discharge criteria, conversion to open surgery, care for comorbidities, or any other condition requiring inpatient admission. The indication for cholecystectomy was established on the next day. The patient admitted to the hospital, and she underwent surgery to remove the gallbladder two days later. The patient responded favorably to treatment and was stable for discharge from the hospital the day following surgery with planned follow up. Acute inpatient care was not medically necessary for this patient, as the care and treatment provided could have been rendered with a lower level of care. A lower level of care would have provided for ED (emergency department) assessment, surgical and GI (gastrointestinal) assessment and monitoring, laparoscopic cholecystectomy, provision of IV (intravenous) antibiotics and fluid, and overnight care. Had surgery been performed on the second day, rather than on the third day, then the patient would have been stable for discharge from the hospital on one day earlier and suitable for a lower level of care.