Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain
Treatment: Inpatient Admission
The insurer denied: Inpatient Admission
The denial is upheld.

The patient is an adult female. She presented to the emergency department with complaint of abdominal pain of one to two days duration. She had been seen for similar complaints and was diagnosed with cholelithiasis/cholecystitis. She was scheduled for elective cholecystectomy but presented to the emergency department due to recurrent symptoms. Her past medical history is notable for hypertension. The patient's vital signs included an elevated heart rate of 103/minute at the time of presentation. Lab data identified a normal white blood cell count of 8.7K thousand), normal serum transaminases, and normal bilirubin. The patient was admitted to the hospital. The surgical history and physical documents a normal white blood cell count of 8.7K (thousand) with normal liver enzymes and bilirubin. Laparoscopic cholecystectomy was recommended and planned for the next day. The patient was started on intravenous antibiotics. Surgery was performed. The operative notes describe a laparoscopic cholecystectomy that was performed without complication. The operative dictation describes a recurrent ventral hernia that did not require acute operative intervention. On post operative day # (number) 1 following surgery, the diet was advanced, and pain was controlled with oral medications. Vital signs were normal. The patient remained clinically stable and was discharged from the inpatient setting. The material submitted for review includes the health plan denial letter. This letter states that inpatient admission to the hospital was not needed in this case following gallbladder surgery and that the care provided could have been rendered with a lower level of care. This letter references MCG (Milliman Care Guidelines). The health plan's denial is being appealed.

The Inpatient Admission was not medically necessary.

The care provided could have been rendered with a lower level of care. A lower level of care would have provided for initial assessment, perioperative care and monitoring, provision of intravenous fluid, surgical consultation, and performance of cholecystectomy. The indication for cholecystectomy was established. There were no peri-procedure complications or other clinical issues. Inpatient care may be needed when there is acute cholangitis with systemic signs of sepsis and evidence of common bile duct disease with bilirubin more than 2 milligrams per deciliter or AST/ALT (aspartate aminotransferase/alanine aminotransferase) 1.5 times upper limit of normal, or imaging showing biliary dilatation or evidence of etiology; Acute cholecystitis (right upper quadrant pain or tenderness, systemic signs of inflammation, Cholecystectomy not anticipated due to high surgical risk or plan for interval cholecystectomy). Also, criteria for inpatient admission may include failure to achieve discharge criteria; conversion to open surgery; severe post-operative infection; care for active comorbidities; complications of procedure; and gallstone ileus. In this case, the patient presented with symptoms related to cholelithiasis/cholecystitis. The evaluation and the indication for cholecystectomy on presentation. The cholecystectomy procedure was performed the next day without complication. The operative report describes performance of cholecystectomy without complication. The patient was stable for discharge from the hospital on the first post-surgical day. The patient responded promptly and without complication to the prescribed therapy (cholecystectomy). The above noted conditions did not exist to warrant an inpatient level of care. The patient's presenting condition at the hospital and clinical course did not justify an inpatient level of care. The care provided could have appropriately been rendered with a lower level of care. Therefore, the inpatient admission was not medically necessary.