Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right upper abdominal pain, nausea, and vomiting.
Treatment: Inpatient Level of Care.
The insurer denied: Inpatient Level of Care.
The denial is upheld.

The patient is an adult female who presented to Hospital emergency department with right upper abdominal pain, nausea, and vomiting of one-week duration. Comorbid health conditions included diabetes, chronic kidney disease and known cholelithiasis. At the time of presentation, the patient was without fever and vital signs were normal. She was tender in the right upper quadrant. The white blood cell (WBC) count was normal at 7.4 thousand. The complete metabolic panel identified normal liver enzymes and normal bilirubin. 
Abdominal ultrasound showed gallstones within the gallbladder and pericholecystic fluid consistent with cholecystitis. The patient was admitted to the hospital. The patient was evaluated with surgery consultation. She was treated with intravenous fluid, nothing by mouth (NPO) status, and intravenous antibiotics. On the day of admission, the patient had episodes of cardiac dysrhythmias for which she was evaluated with electrocardiogram, lab data and cardiology consultation. The patient underwent laparoscopic cholecystectomy on day two. The operation was performed without complication. A drain 
was placed at the time of surgery. The diet was advanced following surgery and pain was controlled with oral medications. The patient remained clinically stable and was discharged from the inpatient setting on day three with planned short term follow up. The health plan rationale for denial per letter references thePlan Utilization Review Guideline Observation Services. This letter states that observation services are considered medically necessary for those who require short term monitoring that is not expected to exceed 24 hours but would generally be no longer than 48 hours and acute treatment and reassessment are required. In this case, the care and treatment provided could have safely been rendered with an observational status and did not require acute inpatient admission.

The proposed treatment was not medically necessary.

An inpatient level of care was not medically necessary in this case. This patient was determined to have cholelithiasis/cholecystitis. There is no documentation of hemodynamic, pulmonary, neurological, or metabolic reason for an acute inpatient level of care at the time of presentation. 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 indication for cholecystectomy was established and surgery was performed on day two without complication. Acute inpatient care was not medically necessary for this patient as the care and treatment provided could have been rendered in the observation setting. An observation level of care would have provided for the initial assessment and imaging, perioperative care and monitoring, provision of intravenous antibiotics and fluid, and overnight care. This lower level of care would have satisfied the clinical needs of this patient and would have been consistent with the standard of care.