Appeal type: Medical necessity
Decision: Upheld

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

The patient is a female who presented with abdominal pain, vomiting, and diarrhea of 1-day duration. Past medical history included hypothyroidism and asthma. At the time of presentation, the patient was without fever, heart rate was 59 and systolic blood pressure was 98 millimeters of mercury (mmHg). She was tender in the right upper abdomen. The white blood cell (WBC) count was 11.4 thousand (K). The complete metabolic panel identified normal serum transaminases and alkaline phosphatase with normal bilirubin. Abdominal ultrasound showed gallstones and a 4-millimeter (mm) common bile duct.
The patient was clinically stable and was receiving intravenous (IV) antibiotics. The patient underwent laparoscopic (robotic assist) cholecystectomy. The operative dictation describes findings of acute cholecystitis. The patient was treated with post-surgical monitoring, intravenous (IV) fluid, IV analgesia, and antiemetics. The immediate post-surgical recovery was uncomplicated. On post-operative day #1 following surgery, the patient had stable vital signs. Pain was controlled with oral medications. The diet was advanced. The patient remained clinically stable and was discharged from the inpatient setting. The subject under review is the medical necessity for the inpatient stay.

An inpatient stay was not medically necessary in this case. This patient presented to the hospital with cholelithiasis/cholecystitis. 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 at a lower level of care status. This would have provided for emergency department (ED) assessment, diagnostic evaluation, perioperative care and monitoring, provision of IV antibiotics and fluid, and overnight care. The indication for cholecystectomy was established with documentation of gallstones noted on ultrasound and upper abdominal pain. Surgery was performed and the patient had an uncomplicated post-surgical recovery. She was able to be discharged from the hospital on the first post-surgical day.

The submitted records included Milliman Care Guidelines (MCG)-Gallbladder or Bile Duct Inflammation or Stone 245h edition. These MCG state that inpatient care may be indicated when there is right upper quadrant pain, and systemic signs of inflammation (fever, C-reactive protein greater than [>] 10, WBC count > 10 K). Inpatient admission may also 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.