Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal Pain
Treatment: Inpatient admission
The insurer denied the inpatient admission 
The denial is overturned.

The patient is a woman. She presented to the hospital ED (emergency
department) with severe abdominal pain and vomiting of
two-days duration. The patient had the comorbid diagnosis of sickle cell disease.

At the time of presentation, the patient was without fever and vital signs were
normal. She did have scleral icterus. The WBC (white blood cell) count was
elevated at 14.1 K (thousand). The complete metabolic panel identified elevated
serum transaminases, alkaline phosphatase and total bilirubin. Abdominal
ultrasound showed gallstones and a sonographic Murphy's sign. She was admitted
to the hospital.

The patient was initially treated with IV (intravenous) fluid and IV (intravenous)
antibiotics. Hematology consultation was requested. Lab data showed further elevation of ALT (alanine aminotransferase), AST (aspartate aminotransferase), and bilirubin (8.8). She was transfused RBCs (red blood cells) for anemia related to her sickle cell condition.

Surgery (cholecystectomy) was performed. The operative dictation describes common bile duct stones noted on cholangiogram. These stones were able to be cleared from the bile duct. However, there was progressive elevation of bilirubin to 10.2. The patient was treated with post-surgical monitoring, IV (intravenous) fluid, IV (intravenous) analgesia, and antiemetics. Lab data showed a reduction in bilirubin to 5.6.

The patient's pain was controlled. The patient's diet was advanced.
The patient remained clinically stable and was discharged.

The health plan rationale for denial of the inpatient admission is that there was no toxicity, significant active comorbidities, hemodynamic instability, bowel obstruction, ascites, or bilirubin greater than 3.0.

Yes, the Inpatient admission was medically necessary in this case, and was consistent with the generally accepted guidelines.

This patient is an adult woman with significant comorbid disease of sickle cell
disease who presented to the hospital with cholelithiasis and choledocholithiasis
(elevated serum transaminases, alkaline phosphatase and total bilirubin). She also
presented with anemia and required transfusion of RBCs (red blood cells) based on
the recommendation of the consulting hematologist. Based on her presenting lab
and imaging data, it was reasonably anticipated that the medically necessary care
would span a period of greater than 48 hours. The patient was appropriately
started on IV (intravenous) antibiotics and was appropriately transfused prior to
surgery. Surgery was appropriately performed (laparoscopic
cholecystectomy with cholangiogram). Postsurgical lab data identified further
elevation of serum bilirubin to 10. Follow up lab data did reveal a trend toward normalization of bilirubin and the patient was clinically stable for discharge from the hospital at this time.

An inpatient designation is needed when there is Failure to achieve discharge
status criteria; Conversion to open surgery; Severe systemic infection; Care for
active comorbidities; Calculus or obstruction of gallbladder or bile duct and one or
more of the following: hemodynamic instability, CBD (common bile duct) obstruction
diagnosed by imaging, vomiting that is severe, dehydration that is severe or
persistent, severe pain, bacteremia; and Complications of the procedure.

In this case, the submitted documentation does support that these clinical
conditions (Calculus or obstruction of gallbladder or bile duct and CBD [common
bile duct] obstruction diagnosed by imaging and significant comorbid disease that
required pre-surgical transfusion) existed to warrant an inpatient level of care.

This patient was treated in an expeditious and efficient manner. The intensity of
service, the coordination of multiple medical services (hematology and surgery), the
diagnoses of sickle cell disease, choledocholithiasis and anemia in addition to
cholelithiasis/cholecystitis support the medical necessity of an inpatient
hospitalization in this case.