Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Epigastric pain

Treatment: Inpatient admission  

The insurer denied coverage for inpatient admission. The denial was upheld.

This patient is a female who presented to the Emergency Department (ED) with complaints of epigastric pain that radiated to her back.  She also reported vomiting 4 times. She was seen at an Urgent Care Center and had an EKG done.  She was sent to the ED for further evaluation. As per the ED note the patient was afebrile with stable vital signs. The patient vomited x 4 and complained of middle upper quadrant tenderness to palpation.  The abdomen was soft, non-distended. As per the provider note the patient presented with epigastric pain x 2 days.  The pain was a burning sensation and localized in the epigastric area.  On exam the epigastric area was tender.   The patient was scheduled for a hepatobiliary iminodiacetic acid (HIDA) scan. White blood cell (WBC) count was 9.32.  Liver function tests (LFT's) were normal.  Ultrasound of the abdomen  revealed 7 mm gallbladder calculus with mild gallbladder thickening at 4mm.  CT of the abdomen revealed trace pericholecystic fluid with a single gall stone. The physician noted that the pain and imaging and clinical signs point towards acute cholecystitis but given her pain, GI should be evaluated for peptic ulcer disease (PUD) and possible endoscopy. HIDA scan report showed normal HIDA scan with prompt filling of the gall bladder.  This confirmed the patency of the cystic duct and makes the diagnosis of acute cholecystitis highly unlikely.  It was noted that the gall bladder responded normally to CCK with an ejection fraction of 47%.

Gastroenterology (GI) was consulted and noted the history and mid-epigastric and right upper quadrant (RUQ) tenderness.  The patient was afebrile with stable vital signs.  "GI noted that patient probably has epigastric pain secondary to gallstone with symptomatic cholelithiasis." The patient also has gastritis and cannot rule out PUD or other pathology.  The plan was for esophagogastroduodenoscopy (EGD) and lap cholecystectomy. General surgery noted that the patient would be having EGD and laparoscopic cholecystectomy. Surgery did note that the abdomen was soft and non-tender. EGD findings included a 5 mm superficial duodenal ulcer in the 2nd portion.  She was taken later that day for a laparoscopic cholecystectomy. She underwent an uneventful cholecystectomy.  Post operatively she did well and was discharged.

Based upon the records the medical necessity of inpatient admission was not justified at an acute level of care as this patient did not have acute cholecystitis and had a prolonged workup for cholelithiasis with a sonogram, CT scan, HIDA scan, EGD and then lap cholecystectomy for what appears in the record as biliary colic with a small duodenal ulcer-none of which required an inpatient hospitalization.  The patient could have had an expedited workup if anything if the provers felt an EGD was necessarily followed by a laparoscopic cholecystectomy and then been sent home after 23 hour observation.

According to the MCG Health Inpatient and Surgical care-23rd Edition Gall bladder or Bile Duct Inflammation or Stone ORG: M-555 (ISC), the clinical indications for admission to inpatient care may include patients with 1 or more specified symptoms. This patient did not have sign and symptoms for acute cholecystitis with normal WBC, liver function tests (LFT's) and most importantly a normal HIDA scan. This ruled out acute cholecystitis. The patient did not meet criteria for admission and could have been treated with observation following EGD and lap cholecystectomy with 23 hours observation.   

Based on the above, the medical necessity for the inpatient admission is not substantiated.  The insurer's denial is upheld.