Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a history of a laparoscopic cholecystectomy 3 weeks earlier who presented to the emergency department with right upper quadrant pain and associated nausea and vomiting. Vital signs in the emergency department were unremarkable except for mild hypertension. The patient had tenderness in the right upper quadrant. Lab results demonstrated a white blood cell count (WBC) of 3.3, total bilirubin of 2.0, aspartate aminotransferase (AST) 440, alanine aminotransferase (ALT) 367, alkaline phosphatase (Alk Phos) 427. Surgery and gastroenterology (GI) were consulted and evaluated the patient. Magnetic resonance cholangiopancreatography (MRCP) had demonstrated a 10 millimeter (mm) common hepatic duct (CHD) with no evidence of choledocholithiasis. The patient underwent an endoscopic retrograde cholangiopancreatography (ERCP). The common bile duct was unable to be cannulated. The pancreatogram was normal. The bilirubin and other liver function tests (LFTs) had improved but the amylase and lipase level were elevated. This was attributed to the ERCP. The amylase and lipase had trended down. The patient's diet was advanced. The patient was decided to be doing well enough to be discharged and be admitted for another attempt at ERCP. The patient was discharged home. At issue is the medical necessity of an inpatient stay.

The patient's admission was not medically necessary at the inpatient level of care for the entire admission. While the patient appears to have had mild hyperbilirubinemia, it is not clear that the patient had cholangitis. Per the Milliman Care Guidelines (MCG) guidelines, inpatient admission is indicated for acute cholangitis, acute cholecystitis when cholecystectomy is not anticipated, and for calculous or obstruction of the gallbladder with certain complications. The patient does not meet criteria for acute cholangitis as this requires systemic signs of inflammation and evidence of common bile duct disease. The patient lacked the systemic signs of inflammation and had recently had imaging that did not suggest the evidence of common bile duct obstruction. The patient does not meet criteria for acute cholecystitis where cholecystectomy is not anticipated. The patient does not meet criteria for calculous or obstruction of the gallbladder or bile duct with hemodynamic instability, common bile duct obstruction, vomiting that is severe or persistent, severe pain requiring acute inpatient management, bacteremia. The patient also does not meet MCG criteria for undiagnosed abdominal pain which requires hemodynamic instability, severe pain, peritoneal signs, identification of an etiology that requires inpatient care, nothing by mouth (NPO) status greater than (>) 24 hours requiring significant intravenous (IV) fluid support, suspected toxic megacolon, bacteremia, procedure that cannot be performed on an ambulatory basis, parenteral nutrition. There is no evidence that additional complex testing or therapy other than the procedure was performed. There is no documentation that the treating team identified conditions or problems specific to the patient that would have required inpatient care. The provided documentation does not support the medical necessity of inpatient level of care. Care could have been provided at a lower level.