Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Choledocholithiasis, gangrenous gallbladder. 
Treatment: Inpatient Admission. 

The insurer denied coverage for inpatient admission. 

The denial is overturned. 

This is the case of a patient with past medical history of gastroesophageal reflux disease (GERD) who presented to the emergency department (ED) with the complaint of epigastric pain, nausea, vomiting, and diaphoresis.  As per the History and Physical, the patient woke from his sleep with nausea and vomiting, diaphoresis worse with lying flat. He stated he had similar presentation 2 weeks ago and was seen in the ED and treated and told he had a possible ulcer. He was given a prescription for heart burn. He did not follow up with his primary medical doctor (PMD). On exam, he had a rigid abdomen with abdominal tenderness. He is obese. Labs included WBC (white blood cell) 11.7, Alkaline phosphatase of 169, Liver function tests (AST [ Aspartate aminotransferase]151, ALT [alanine aminotransferase] 93) and total bilirubin of 1.7. The ED note indicated the pain persisted and the decision was to send the patient for a computed tomography (CT) of the abdomen. 

The inpatient admission was justified as this patient could not have been managed as noted by the insurer in an ambulatory/observation setting as he had choledocholithiasis as well as a gangrenous gallbladder requiring an ERCP (Endoscopic retrograde cholangiopancreatography) and laparoscopic (lap) fenestrated cholecystectomy. According to the guidelines of MCG (Milliman Care Guidelines) Health Inpatient and Surgical Care- 26th edition Gall bladder or bile duct inflammation or stone ...patients may be discharged to a lower level of care (either later than or sooner than the goal) when it is appropriate for their clinical status and care needs. The  clinical indications for admission to inpatient care may include patients with 1 or more of the following:  Acute cholangitis as indicated by all of the following: Systemic signs of inflammation indicated by 1 or more of the following: Fever, C-reactive protein level greater than 10 mg/L (milligrams per liter), ...High surgical risk (e.g., severe comorbidities, organ failure), Interval cholecystectomy planned (i.e., not during current hospitalization); Calculus or obstruction of gallbladder or bile duct and 1 or more of the following: Hemodynamic instability, Common bile duct obstruction diagnosed (e.g., by imaging), Vomiting that is severe or persistent, Dehydration that is severe or persistent,  Severe pain requiring acute inpatient management,  Bacteremia. This patient did need to be admitted as he could not have been managed with an outpatient or ambulatory basis. He did have indication for acute inpatient admission given that he had markedly abnormal liver function test with evidence of CBD (common bill duct) obstruction requiring ERCP and markedly inflamed gallbladder with necrosis of the mucosa. The patient could not have been cared for with an ambulatory observation setting. 

Furthermore, although according to MCG Inpatient and Surgical Care 26th Edition cholecystectomy by laparoscopy the operative status criteria is ambulatory, this patient had CBD obstruction requiring an ERCP followed by lap cholecystectomy at which time the surgeon made the correct decision of doing a fenestrated cholecystectomy. Thus, this patient could not have been managed without an inpatient acute admission for this procedure. 

The health care plan did not act reasonably and with sound medical judgment. 
The insurer's denial of coverage for the inpatient admission is overturned. Medical necessity is substantiated.