Appeal type: Medical necessity
Decision: Upheld


Diagnosis: Abdominal Pain
Treatment: Inpatient Hospital 
The health plan denied the requested inpatient hospital stay. The health plan's determination is upheld.

The patient is a female with a medical history of a partial cholecystectomy, and coronary artery disease status post three stent placements on Plavix, diabetes mellitus, hyperlipidemia, hypertension, and gastroesophageal reflux disease (GERD), . She presented to the emergency department with two days of right upper quadrant abdominal pain radiating to the back, with one episode of emesis. Vital signs were notable for elevated blood pressure of 187/85 millimeters of mercury (mmHg). Physical examination was notable for abdominal tenderness in the right upper quadrant and epigastric area, and right costovertebral angle tenderness. Labs showed elevated white blood cell count of 11.2 K/uL, an elevated alkaline phosphatase of 230 U/L, an elevated lipase of 246 U/L, and an elevated lactate of 3.2 mmol/L. Computed tomography scan of the abdomen and pelvis showed prior cholecystectomy, dilation of the proximal and mid-common bile duct measuring up to 1.3 centimeters (cm) in diameter, hyperdense foci in the proximal and mid-common bile duct up to 9 millimeters (mm) most compatible with choledocholithiasis, and cecal and ascending colon diverticulosis. Ultrasound showed a fatty and enlarged liver, absent gallbladder, dilated common bile duct up to 1.3 cm in maximal diameter, and a 1.0 cm stone in the mid- to distal common bile duct. She was treated with intravenous fluids, Zosyn, and Morphine. She was made nil per os. Magnetic resonance cholangiopancreatography showed a dilated cystic duct remnant which contained stones, common bile duct diameter of 4 mm, and choledocholithiasis with tiny stones in the distal common bile duct but no intrahepatic or extrahepatic biliary dilation. She was transferred to a tertiary care center to undergo endoscopic retrograde cholangiopancreatography. At issue is coverage for the inpatient level of care.

The health plan's determination of medical necessity is upheld, in whole.

No, as the acute inpatient level of care is not supported. In this case, the patient presented with choledocholithiasis, which warranted endoscopic retrograde cholangiopancreatography (ERCP) for therapy, but there was no hypotension, hemodynamic instability, ascending cholangitis, sepsis, hepatic abscess, or active gastrointestinal bleeding which would require a higher level of care [1-6]. Temporary discontinuation of Clopidogrel warranted consideration including a cardiology consultation given the likelihood of sphincterotomy during ERCP, although this would not warrant the inpatient level of care during the short stay at issue [7] . All of the measures that were undertaken, including monitoring, empiric antibiotic therapy, gastroenterology and surgery consultations, and imaging, could have been performed without acute inpatient level of care, at the observation level of care [2-4].
A general surgery consultation concluded that she had choledocholithiasis and recommended magnetic resonance cholangiopancreatography and a gastroenterology consultation for endoscopic retrograde cholangiopancreatography. Gastroenterology consultation concluded that she had choledocholithiasis and dilated common bile duct, with no cholangitis, and recommended stopping Plavix, cardiology evaluation, endoscopic retrograde cholangiopancreatography the next week approximately five days after stopping Plavix, and earlier intervention if cholangitis or jaundice.