Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a woman. She presented to the hospital with abdominal pain. She was transferred to another facility.

At the time of presentation, the patient was without fever. Her vital signs showed a normal heart rate and blood pressure.  She was tender in the right upper abdomen.  The WBC (white blood cell) count was normal at 6.5 K (thousand).  The complete metabolic panel identified normal serum transaminases, bilirubin, and alkaline phosphatase.  Ultrasound and CT (computed tomography) scan showed gallstones, a mildly thick gallbladder wall and a normal caliber common bile duct (CBD).  Intra and extra-hepatic ducts were not dilated.

The patient was initially treated with IV (intravenous) fluid, pain medications and anti-emetics.  She was initially scheduled for cholecystectomy, but she had eaten in the early morning, and so surgery was postponed.  The patient was treated with laparoscopic cholecystectomy the following day.  The operative dictation and the anesthetic record describe an uncomplicated cholecystectomy procedure.

The patient was treated with post-surgical monitoring, IV (intravenous) fluid, IV (intravenous) analgesia, and anti-emetics.  The immediate post-surgical recovery was uncomplicated. Following surgery, the patient had stable vital signs.  Pain was controlled.  The diet was advanced.  The patient remained clinically stable and was discharged from the inpatient setting.

The health plan letter and the hospital appeal letter reference MCG (Milliman care guidelines) 24th edition Cholecystectomy by laparoscopy.  The health plan letter states that hospital admission was not medically necessary.

No, the Inpatient admission  was not medically necessary.
This patient is a previously healthy woman who presented to the hospital with 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, procedural complications, or any other condition requiring inpatient admission.  Acute inpatient care was not medically necessary for this patient, as the care and treatment provided could have been rendered at a lower level of care.  A lower level of care would have provided for ED (emergency department) assessment, surgical assessment, imaging with ultrasound and CT (computed tomography) scan, perioperative care and monitoring, provision of IV (intravenous) fluid and medication, and overnight care.  

There is no documented compelling reason as to why this patient could not have been safely and appropriately treated at a lower level of care. Based on the submitted clinical documentation, an inpatient level of care was not medically necessary.

This patient was admitted to the hospital  with the diagnosis of cholelithiasis/cholecystitis. Her pre-surgical assessment and the indication for surgery was established as of the admission day. The patient underwent an uncomplicated laparoscopic cholecystectomy procedure two days later. There were no peri-operative complications or other clinical issues. She remained stable and was discharged from the hospital on the first post-surgical day.

Inpatient level of care was not medically necessary. A lower level of care would have permitted for the pre-surgical assessment, the surgical procedure and perioperative IV (intravenous) fluid, IV (intravenous) antibiotics, IV (intravenous) antiemetics, and post-surgical monitoring. The patient was clinically stable following surgery, as supported by the corresponding medical records.

An inpatient level of care was not required for the care and treatment of this patient. The medical record supports that the patient could have been reasonably and appropriately treated at a lower level of care.

The submitted records document that this patient was clinically and hemodynamically stable at the time of presentation. The WBC (white blood cell) count was normal. Serum chemistries identified normal transaminases. Surgery was performed and the perioperative period was uncomplicated. Inpatient stay may be needed for failure to achieve discharge status criteria, conversion to open surgery, systemic infection, care for active comorbidities, complications of procedure. A lower level of care would have satisfied the clinical needs of this patient.

The referenced MCG (Milliman Care Guidelines)- Gallbladder or Bile Duct Inflammation, Inpatient and Surgical Care 24th edition- state that inpatient care is indicated when there is right upper quadrant pain, and systemic signs of inflammation (fever, C-reactive protein > 10, WBC [white blood cell] count > 10 K [thousand]). Inpatient admission is also indicated for acute cholangitis, common bile duct obstruction, vomiting that is severe or persistent, dehydration that is severe or persistent, hemodynamic instability, severe pain requiring acute inpatient management, signs of intestinal obstruction, bacteremia, need for percutaneous or open procedures, or other condition that requires inpatient admission.

In this case, none of these indications existed to justify an inpatient level of care.