Appeal type: Medical necessity
Decision: Upheld

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

The patient is a woman. She presented to the ED (emergency department) with abdominal pain and vomiting of several days duration.

At the time of presentation, the patient was without fever, and vital signs were normal. She was tender in the right upper quadrant. The WBC (white blood cell) count was normal at 10.1 K (thousand). The complete metabolic panel identified elevation of serum transaminases with normal bilirubin. Abdominal ultrasound showed gallstones. HIDA (hepatobiliary iminodiacetic acid) scan showed non-visualization of the gallbladder and no evidence of small bowel contrast consistent with common duct obstruction.

The patient was admitted to the hospital and initially treated with IV (intravenous) fluid, antibiotics, and antiemetics. Surgery consultation was obtained. Laparoscopic cholecystectomy was performed. A cholangiogram was not performed. The patient was started on a liquid diet following surgery. Day two, the patient had normal vital signs. She was tolerating a liquid diet. Pain was controlled. 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 with abdominal pain and vomiting. She was determined to have 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, or any other condition requiring inpatient admission. The indication for cholecystectomy was established. The patient responded favorably to the treatment provided and was stable for discharge from the hospital.

Acute inpatient care was not medically necessary for this patient as the care and treatment provided could have been rendered with a lower level of care. A lower level of care would have provided for ED (emergency department) assessment, surgical assessment and cholecystectomy, provision of IV (intravenous) antibiotics and fluid, 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 reason why this patient could not have safely and appropriately been treated with a lower level of care with subsequent transition to outpatient care. Inpatient level of care was not medically necessary. A lower level of care would have permitted for the surgical assessment, the surgical procedure, and perioperative IV (intravenous) fluid, IV (intravenous) antibiotics, IV (intravenous) antiemetics, and overnight monitoring. The submitted records document that this patient was clinically and hemodynamically stable at the time of presentation. The patient was clinically stable throughout the period of monitoring as supported by the corresponding medical records.

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. While the HIDA (hepatobiliary iminodiacetic acid) scan showed nonvisualization of the gallbladder and no transit of contrast into the small bowel, the records indicate that no cholangiogram was performed to confirm common duct obstruction and the patient was considered to be stable for discharge from the hospital on the first post-surgical day.