Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal- Cholecystitis/Inflammation of the gallbladder.
Treatment: Inpatient hospital stay.
The health plan denied the inpatient stay as not medically necessary. 
The reviewer has upheld in whole the health plan's determination. 

The patient presented to the emergency department (ED) with abdominal pain, nausea, and vomiting of 1-day duration. She had been seen 2-days earlier with the same symptoms and had been discharged from the ED. Past medical history included anxiety and asthma. At the time of presentation, the patient was without fever, heart rate was 100 and blood pressure was 112/70 millimeters of mercury (mmHg). She was tender in the right upper abdomen and epigastrium. The white blood cell count (WBC) was 10.4 thousand (K). The complete metabolic panel identified normal serum transaminases and alkaline phosphatase with normal bilirubin. Abdominal ultrasound showed gallstones, no gallbladder wall thickening, and a 3.6-millimeter (mm) common bile duct.
The patient underwent laparoscopic cholecystectomy. The operative dictation describes cholecystitis. She was clinically stable following surgery and 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.

No. An inpatient level of care was not medically necessary in this case. This patient presented to the hospital with cholelithiasis/cholecystitis. The indication for cholecystectomy was established the next day. The patient underwent an uncomplicated laparoscopic cholecystectomy procedure. There were no peri-operative complications or other clinical issues. She remained stable and was discharged from the hospital. 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. A lower level of care would have provided for the ED assessment, diagnostic evaluation, perioperative care and monitoring, provision of IV antibiotics and fluid, and overnight care. The patient was clinically stable following surgery as supported by the corresponding medical records. The medical record supports that the patient could have been reasonably and appropriately treated with a lower level of care.
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.
The documentation in this case does not support that these criteria were satisfied to justify an inpatient level of care.