Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute onset right upper quadrant abdominal pain
Treatment: Inpatient hospital stay
The health plan denied the requested inpatient hospital stay as not medically necessary.
The health plan's determination is partially overturned.

The patient is a man who presented to the emergency department (ED) with right sided abdominal pain. He has a history of morbid obesity, hypertension, and diabetes. At the time of presentation, the patient was without fever and the heart rate was 110/minute. He had a tender abdomen per the examination. The white blood cell count was elevated at 12.4. The complete metabolic panel was normal. A computed tomography (CT) scan and ultrasound showed findings of gallstones. He was initially treated with intravenous (IV) fluid and IV antibiotics. Surgical consultation was obtained, and the treatment plan was for a laparoscopic cholecystectomy.

On the following day, the patient manifested hypoxia with oxygen saturations of 85-87%. He was treated with supplemental oxygen. A CT angiogram of the chest was negative for acute pulmonary embolism. He was treated with nocturnal continuous positive airway pressure (CPAP) and supplemental oxygen at 3 liters nasal canula. He was also noted to have umbilical erythema that had increased since the day before. He was treated with IV antibiotics for this cellulitis. Lab data identified a normal white blood cell (WBC) count. The diet was advanced and physical therapy was consulted. The next day the patient demonstrated oxygen desaturations to 88% while off oxygen. He was not able to tolerate the CPAP appliance. The umbilical erythema was noted to be improving. The following day, vital signs were normal, and he was receiving IV Zosyn for umbilical erythema. The patient was discharged home with oral antibiotics. He was able to maintain oxygen saturation of at least 90% without supplemental oxygen at this time.
At issue is the medical necessity for the inpatient stay.

The health plan's determination is overturned, in part.

This patient was a man who presented to the hospital with abdominal pain. The records and the diagnostic work up supported the diagnosis of cholelithiasis/cholecystitis. The patient was treated expeditiously and underwent surgery to remove the gallbladder. However, his post-surgical course was complicated by significant hypoxia that required evaluation with CT angiogram of the chest and provision of supplemental oxygen. He also developed a wound cellulitis that required treatment with IV antibiotics. However, later, the records support that he was stable to discharge from the hospital and that he could have been provided with supplemental oxygen in the alternate setting rather than during continued inpatient confinement.

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. In this case, the patient did not meet discharge criteria due to hypoxia and required provision of IV antibiotics for wound cellulitis. These clinical issues did warrant an inpatient level of care during this time.

The records support that an inpatient level of care was medically necessary, but that continued inpatient care was not necessary on the last two days.