Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal pain. 
Treatment: Inpatient admission. 
The insurer denied the inpatient admission. 
The determination is overturned. 

This is a female patient who presented to the emergency department (ED) with recurrent episodic abdominal pain and recent admission for cholelithiasis with common bile duct dilation. She had been discharged earlier in the day with close surgery follow-up and plans for a cholecystectomy. She woke up from sleeping with inconsolable crying, curling up in pain. She vomited once after arrival to the emergency department (ED). Pediatric Surgery was consulted with a recommendation for ultrasound, nothing by mouth, and intravenous (IV) fluids. An ultrasound was negative for intussusception, revealing cholelithiasis with gallbladder wall thickening and hyperemia and a non-mobile stone and mildly common bile duct dilation, two large right ovarian cysts and one large left ovarian cyst. She was admitted for possible surgical management. 

Admission orders included Ceftriaxone, repeat gallbladder ultrasound, expected cholecystectomy, additional labs per gastroenterology, and pre-operative labs. She had no vomiting overnight. The pain was successfully treated with Tylenol. A repeat ultrasound was negative for gallstones, yielding no indication for cholecystectomy. She was instead started on ursodiol per pediatric gastroenterology. Follow-up with pediatric hematology and pediatric surgery was also recommended. She was subsequently deemed stable for discharge home. At issue is the medical necessity of an inpatient stay. 

Acute inpatient admission was medically necessary. Infantile cholelithiasis is a rare condition that may require surgical management or may resolve spontaneously. Conservative non-surgical management may include medication or endoscopic retrograde cholangiopancreatography. Risk factors include total parenteral nutrition (TPN), diuretics, specific antibiotics, congenital heart disease, prematurity, or malabsorption. Complications include choledocholithiasis, cholecystitis, and pancreatitis. This young female infant with cholelithiasis and intended surgery presented after discharge from the hospital earlier that day with pain and inconsolable crying. She had no laboratory evidence of pancreatitis, but ultrasound revealed cholelithiasis and ovarian cysts. She was admitted in anticipation of cholecystectomy. While she had vomiting in the emergency department (ED), she had no further vomiting following admission. She was monitored closely with both pediatric surgery and pediatric gastroenterology consulting. Prior to anticipated surgery, another ultrasound was obtained revealing resolution of cholelithiasis. There was no longer indication for surgical management, and she was placed on ursodiol prior to discharge. While she was not hospitalized for a long time and ultimately did not require parenteral pain management or surgical intervention, she presented with signs and symptoms leading toward need for surgery. The level of care necessary in this rare and complicated situation was most consistent with acute inpatient management regardless of duration of hospital stay.