Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest/abdominal Pain. 
Treatment: Inpatient Hospital Admission. 

The insurer denied: Inpatient Hospital Admission. 
The denial is overturned. 

The patient is an adult female with chronic medical problems of obesity, anxiety, asthma, opioid dependence, COPD (chronic obstructive pulmonary disease) on home oxygen, bipolar disorder, hypertension, hypothyroidism, and recently diagnosed lung cancer. She presented to ED (emergency department) with chest/abdominal pain. At the time of presentation, the patient was without fever and vital signs were normal. In the course of her ED (emergency department) evaluation, her pain localized to the abdomen. Lab data and imaging results (CT [computed tomography] scan on the next day) identified gallstones / cholecystitis and biliary ductal dilatation. The patient was admitted to the hospital and initially treated with IV (intravenous) fluid, antibiotics, and anti-emetics. Surgery consultation was obtained, and she was treated with laparoscopic cholecystectomy the following day. The operative dictation and the anesthetic record completion of the procedure (2-hours) without complication, though this was a difficult procedure due to the degree of inflammation. The pathology report documents completely denuded gallbladder with chronic cholecystitis, extensive wall fibrosis and calcifications, and cholelithiasis. 

The patient was treated with post-surgical monitoring, IV (intravenous) fluid, IV (intravenous) antibiotics, analgesia, and antiemetics. The surgical drain had serosanguinous fluid in the reservoir post-operatively. The patient's serum transaminases were slightly elevated on post operative day #1. The patient 
had normal vital signs. She was tolerating a liquid diet. Her pain was controlled. The patient remained clinically stable and was discharged from the inpatient setting on postoperative day #2 with the surgical drain kept in place. The health plan denied coverage for the inpatient admission with the contention that MCG (Milliman Care Guidelines) criteria were not met. The denial is being appealed. 

The Inpatient Hospital Admission was medically necessary. 

Acute inpatient care was medically necessary for this patient as the care and treatment provided could not have been appropriately rendered with a lower level of care. The records support appropriate and expeditious care, performance of surgery and provision of IV (intravenous) antibiotics and drain care over a period of time that spanned greater than 48-hours, required the coordinated care of multiple medical services for the documented condition of acute and chronic cholecystitis with extensive wall fibrosis and calcifications, and cholelithiasis. 

MCG (Milliman Care Guidelines) state that inpatient care may be needed when there is:
Right upper quadrant pain, mass or tenderness AND fever, C-reactive protein > 10 or WBC (white blood cell) count > 10 K (thousand). Acute cholecystitis as indicated by all of the following: fever, C-reactive protein > 10 or WBC (white blood cell) count > 10 K (thousand), Evidence of bile duct disease, Common bile duct obstruction, Vomiting that is severe, Dehydration, Hemodynamic instability, Severe pain, Bacteremia. 

In this case, there was marked acute and chronic cholecystitis as documented and confirmed by the operative findings and pathology report. The patient had substantial comorbid health conditions and required pre-and post-surgical monitoring that reasonably spanned a period of greater than 48-hours.