Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Inpatient Hospital. 
The insurer denied Inpatient Admission. 
The denial is upheld. 

The patient is a female who presented to the emergency department (ED) with epigastric abdominal pain. At the time of presentation, the patient was without fever and the heart rate was elevated at 110/minute. She had a tender abdomen per the examination. The white blood cell (WBC) count was elevated at 17.4. The complete metabolic panel was normal. A computed tomography (CT) scan and ultrasound showed findings of cholecystitis. She was initially treated with intravenous (IV) fluid and IV antibiotics. Consultation note stated that cholecystectomy was planned. She was treated with 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. Her pain was controlled with oral medications. The diet was advanced. The patient remained clinically stable and was discharged from the inpatient setting.
At issue is the medical necessity of the Inpatient Admission.

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

The requested health service/treatment of Inpatient Admission was not medically necessary for this patient.
There is no clinical documentation to support the need for inpatient admission. 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. The indication for cholecystectomy was established. The submitted records document that this patient was clinically and hemodynamically stable at the time of presentation. The serum chemistries were normal at the time of presentation. The patient underwent an uncomplicated laparoscopic cholecystectomy procedure. There were no peri-operative complications or other clinical issues that mandated an inpatient designation. She remained stable and was discharged from the hospital following surgery. 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. The patient was clinically stable following surgery as supported by the corresponding medical records. She was tolerating a diet and oral analgesia following surgery.
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. In this case none of these conditions existed to warrant an inpatient level of care. Inpatient admission may be 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.
Therefore, the requested health service/treatment of Inpatient Admission was not medically necessary.