Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain, nausea, and vomiting. 
Treatment: Inpatient admission. 

The insurer denied the inpatient admission. 
The denial is upheld. 

The patient is a man. He presented to the hospital ED (emergency department) with abdominal pain, nausea, and vomiting. His comorbid health conditions included hyperlipidemia, hypertension, history of pulmonary embolism and diabetes. 

At the time of presentation, the patient was without fever. His vital signs showed a normal heart rate and blood pressure. He was tender in the right upper abdomen. The WBC (white blood cell) count was 9 K (thousand). The complete metabolic panel identified elevated serum transaminases with normal bilirubin and alkaline phosphatase. Abdominal ultrasound showed gallstones. He was initially treated with IV (intravenous) fluid, pain medications and antiemetics. He was treated with laparoscopic cholecystectomy. The operative dictation and the anesthetic record describe an uncomplicated cholecystectomy procedure with an acutely inflamed gallbladder. 

The patient was treated with post-surgical monitoring, IV fluid, IV analgesia, and antiemetics. The immediate post-surgical recovery was uncomplicated. Day two, the patient had stable vital signs. Pain was controlled. The diet was advanced. The patient remained clinically stable and was discharged from the inpatient setting. 

The health plan letter references MCG (Milliman Care Guidelines) 24th edition Cholecystectomy by Laparoscopy. The health plan letter states that hospital admission was not medically necessary, as there were no serious problems such as fever, persistent vomiting, or severe pain that required inpatient stay. 

No, the inpatient admission was not medically necessary. 

This patient is a man who presented to the hospital 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 at a lower level of care. A lower level of care would have provided for ED assessment, surgical assessment, imaging with ultrasound and/or CT (computed tomography) scan, perioperative care and monitoring, provision of IV fluid and medication, and overnight care. 

Yes, the health plan did act reasonably, with sound 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 a lower 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. The pre-surgical 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. The patient remained stable and was discharged from the hospital on the first post-surgical day. 

Inpatient level of care was not medically necessary. A lower level of care would have permitted for the pre-surgical assessment, the surgical procedure and perioperative IV fluid, IV antibiotics, IV antiemetics, and post-surgical monitoring. The patient was clinically stable following surgery, as supported by the corresponding medical records. The medical record supports that the patient could have been reasonably and appropriately treated with a lower level of care.

The submitted records document that this patient was clinically and hemodynamically stable at the time of presentation. Serum chemistries identified elevated transaminases with 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. A lower level of care would have satisfied the clinical needs of this patient. 

The referenced 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 count > 10 K). 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.