Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal pain, nausea, vomiting
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is overturned.

The patient is a female who presented with severe and worsening abdominal pain, nausea, and vomiting of five-days duration.  Comorbid health conditions included current pregnancy  (34 weeks, two days).  At the time of presentation, the patient was without fever and vital signs were notable for a blood pressure of 104/72 millimeters of mercury (mmHg).  The heart rate was 95 beats per minute.  She was tender in the upper quadrants and reported her pain as ten out of ten.  The white blood cell (WBC) count was elevated at 10.8 thousand.  The complete metabolic panel identified normal bilirubin.  Alanine aminotransferase (ALT) was elevated at 46.  Ultrasound showed gallbladder stones and distention consistent with acute cholecystitis.  

The patient was admitted to the hospital and initially treated with intravenous fluid, antibiotics, and antiemetics.  Surgery and maternal fetal medicine consultations were obtained.  Initially surgical intervention was not planned as the patient was a high surgical risk due to her third trimester pregnancy.  The patient was kept nothing by mouth (NPO).  She complained of worsening abdominal pain.  Due to her worsening symptoms, she was treated with emergent laparoscopic cholecystectomy.  The obstetrical team was present during this procedure and monitored fetal heart tones throughout surgery.  The operative dictation and the anesthetic record describe findings of acute cholecystitis.  The procedure was completed without complication. The patient was monitored by the obstetrical team.  The patient was treated with post-surgical monitoring, intravenous fluid, intravenous analgesia, and antiemetics.  She was stable from the standpoint of the surgical service and the obstetrical service and she was discharged from the inpatient setting.

Yes, inpatient admission was medically necessary for this patient.
This patient is a female who presented to the hospital with acute cholelithiasis/cholecystitis.  Presurgical imaging and lab data supported the diagnosis of acute cholecystitis and the operative findings confirmed that there was acute cholecystitis.  Additionally, this patient was in her third trimester of pregnancy and required the coordinated care of the obstetrical and surgical services.  The patient required provision of intravenous antibiotics to treat the acute infectious/inflammatory condition, urgent surgery, and continued post-surgical monitoring and fetal monitoring.  The records support timely, expeditious, and medically appropriate care.  While the early post-surgical recovery was uncomplicated, she did need treatment for acute cholecystitis, urgent surgery, peri-operative, intra-operative and post-operative fetal monitoring, intravenous fluid and antiemetic therapy during a hospitalization that was reasonably anticipated to extend for at least 48-hours.

In this case there is documentation of severity of disease, an anticipated length of stay greater than 48-hours, need for coordinated care of multiple medical services, and provision of intravenous antibiotics for an acute infectious condition that required inpatient admission.  

General guidelines support that inpatient care is indicated when there is right upper quadrant pain, AND systemic signs of inflammation (fever, C-reactive protein greater than ten, white blood cell [WBC] count greater than ten thousand).  Inpatient admission is also 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.  

In this case, the patient had acute cholecystitis, a third trimester pregnancy, and required intravenous antibiotics and acute surgical management to justify an inpatient level of care.

No, the health plan did not act reasonably or with sound medical judgment with its determination in this case.  Acute inpatient admission was medically necessary for this patient.