Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain, Vomiting.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient presented to the emergency department (ED)  with right upper quadrant abdominal pain and vomiting of several days duration. She had previously been evaluated at another ED for these complaints. At the time of presentation she was without a fever and the heart rate was elevated at 104 beats/minute. She had a tender right upper abdomen per the examination. The white blood cell count (WBC) count was elevated at 13.78 thousand (K). The complete metabolic panel identified elevated transaminases with normal bilirubin. The ultrasound showed findings of gallstones without wall thickening or pericholecystic fluid. The initial assessment was that of nausea, vomiting and abdominal pain in the setting of known cholelithiasis. However, there was no plan for acute surgical intervention. The progress note states that a cholecystectomy was planned. The patient was receiving intravenous (IV) antibiotics and she was provided a liquid diet. She was treated with a laparoscopic cholecystectomy. The operative dictation and the anesthetic record describe an uncomplicated cholecystectomy procedure.
The patient was treated with post-surgical monitoring, IV fluid, IV analgesia, and antiemetics. The immediate post-surgical recovery was uncomplicated. The pain was controlled with oral medications following surgery. The diet was advanced. The patient remained clinically stable and was discharged from the inpatient setting.
At issue is the medical necessity of an inpatient stay.

An inpatient level of care was not medically necessary in this case. 

This patient presented to the hospital with cholelithiasis/cholecystitis. She did have an elevated WBC count and was tender in the right upper quadrant. Based on her clinical condition and diagnostic test results, the indication for cholecystectomy was established. However, 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 with a lower level of care. A lower level of care would have provided for ED assessment, surgical consultation, cholecystectomy, perioperative care and monitoring, provision of IV antibiotics and fluid, and overnight care. While the indication for cholecystectomy was established, the patient did not undergo surgery for several days.
There were no peri-operative complications or other clinical issues that mandated an inpatient stay. She remained stable and was discharged from the hospital.
Inpatient level of care was not medically necessary. The patient was clinically stable following surgery as supported by the corresponding medical records. She was tolerating a diet and oral analgesia following the surgical procedure.