Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld

The patient is a woman who presented with abdominal pain of 1-day duration. Comorbid health conditions included high lipids, schizophrenia and migraine headaches.

At the time of presentation the patient was without fever and vital signs showed a normal heart rate and blood pressure of 130/90 mmHg (millimeters of mercury). She was tender in the right upper abdomen. The WBC (white blood cell) count was 10.9 K (thousand). The complete metabolic panel identified elevated serum transaminases with normal bilirubin. Ultrasound showed gallstones, a mildly thick gallbladder wall and a normal caliber common bile duct (CBD). Intra and extra-hepatic ducts were not dilated. She was admitted to the hospital. She was initially treated with IV (intravenous) fluid, pain medications and antiemetics. She was treated with laparoscopic cholecystectomy. The operative dictation and the anesthetic record describe an uncomplicated cholecystectomy procedure.

The patient was treated with post-surgical monitoring, IV (intravenous) fluid, IV (intravenous) analgesia, and antiemetics. The immediate post-surgical recovery was uncomplicated. Following surgery, the patient had stable vital signs. The patient did complain of generalized pain. The diet was advanced. The patient remained clinically stable and was discharged from the inpatient setting.

No, the Inpatient admission was not medically necessary.
An inpatient level of care was not medically necessary in this case. This patient is a woman who presented to the hospital ED (emergency department) with cholelithiasis/cholecystitis. 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 in the observational setting. An observational level of care would have provided for ED (emergency department) assessment, surgical assessment, imaging with ultrasound, perioperative care and monitoring, provision of IV (intravenous) fluid and medication, and overnight care. The patient was admitted to the hospital. The care provided during this time could have reasonably been rendered with an observation level of care.

Yes, the health plan did act reasonably, with sounds medical judgment, and in the best interest of the patient.
There is no compelling documented reason why this patient could not have safely and appropriately been treated at the observation level of care. Based on the submitted clinical documentation, an inpatient level of care was not medically necessary. This patient was admitted to the hospital with the diagnosis of cholelithiasis/cholecystitis. Her presurgical assessment and the indication for surgery was established. 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.

Inpatient level of care was not medically necessary. An observation level of care would have permitted for the pre-surgical assessment, the surgical procedure and perioperative IV (intravenous) fluid, IV (intravenous) antibiotics, IV (intravenous) antiemetics, and post-surgical monitoring. The patient was clinically stable following surgery as supported by the corresponding medical records.

The submitted records document that this patient was clinically and hemodynamically stable at the time of presentation. The WBC (white blood cell) count was 10.9 K (thousand). Serum chemistries identified elevated serum transaminases and normal bilirubin. Surgery was performed and the perioperative period was uncomplicated. Inpatient stay may be needed for failure to achieve discharge status criteria, conversion to open surgery, systemic infection, care for active comorbidities, complications of procedure. An observational level of care would have satisfied the clinical needs of this patient.

The referenced MCG (Milliman Care Guidelines)- Gallbladder or Bile Duct Inflammation, Inpatient and Surgical Care 24th edition. These MCG (Milliman Care Guidelines) state that inpatient care is indicated when there is right upper quadrant pain, AND systemic signs of inflammation (fever, C-reactive protein > [greater than] 10, WBC [white blood cell] count > [greater than] 10 K [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, none of these indications existed to justify an inpatient level of care.