Appeal type: Medical necessity
Decision: Upheld

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

This patient presented with right upper quadrant (RUQ) abdominal pain which had been occurring for the past 2 days and was worse at night. The patient was afebrile with stable vital signs. On exam there was moderate RUQ abdominal tenderness and pain with a positive Murphy's sign. White Blood Cell (WBC) count was 7.3, alanine transaminase (ALT) was 32, aspartate aminotransferase (AST) 33 and bilirubin of 1.2. Sonogram of the abdomen revealed a 1.6 centimeter (cm) hyperechoic stone within the gallbladder. The gallbladder wall was thickened. There was no pericholecystic fluid. The findings may be consistent with acute cholecystitis. Surgical consult was called.

General surgery saw the patient and noted in their consult note that the patient has had multiple similar episodes of RUQ abdominal pain. Exam revealed mild abdominal tenderness in the RUQ. The abdomen was non distended. The plan was admit to surgery, place on nothing by mouth (NPO) status and surgery for laparoscopic cholecystectomy.

Progress notes indicated the patient had no acute events overnight and was scheduled for surgery. The WBC was 5.2. A note indicated that the patient did not want surgery at this time. They will give oral intake and if tolerated the patient will be discharged to home.

The acute inpatient admission was not justified as this patient could have been managed as noted by the insurer in an ambulatory/observation setting as she did not have surgery and elected to go home. All that was required was observation. In fact, the patient most likely had biliary colic and not acute cholecystitis and therefore did not warrant acute inpatient admission. There was not an elevated WBC or elevated liver function tests. There was no fever; she had abdominal pain.

According to the Milliman Care Guidelines (MCG) Health Inpatient and Surgical Care- 26th edition Gall bladder or bile duct inflammation or stone ORG: M-555 (ISC) patients may be discharged to a lower level of care (either later than or sooner than the goal) when it is appropriate for their clinical status and care needs.

In addition according to MCG Inpatient and Surgical Care 26th Edition Abdominal Pain, Undiagnosed ORG: M-05 (ISC) admission may be indicated for 1 or more of the following:  Hemodynamic instability;  Severe pain requiring acute inpatient management; Peritoneal signs; Identification of etiology or finding that requires inpatient care (e.g., aortic dissection, bowel perforation, bowel ischemia, visceral organ torsion; intestinal obstruction); Evaluation requires patient to not eat or drink for extended period (e.g., more than 24 hours); Inability to maintain oral hydration (e.g. needs IV fluid support) that persists after emergency department and observation care treatment; Suspected toxic megacolon; Bacteremia; Procedure that cannot be performed on ambulatory basis.

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for inpatient admission is upheld. Medical Necessity is not substantiated.