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201905-116861

2019

Healthfirst Inc.

Medicaid

Digestive System/ Gastrointestinal

Inpatient Hospital

Medical necessity

Upheld

Case Summary

Diagnosis: Abdominal pain, Acute Cholecystitis
Treatment: Inpatient Hospital

Summary: This patient was seen in the Emergency Department (ED) for complaints of abdominal pain. She stated that she did have a cesarean section three weeks prior and was diagnosed with pancreatitis at a different facility. On examination she had a temperature of 98.0°F with a heart rate of 75 beats per minute (bpm). The patient's blood pressure was 115/45, and her oxygen saturation was 98%. The physical exam revealed she was alert and oriented and in no acute distress. The patient was recommended to undergo laboratory and diagnostic studies. The Computed Tomography (CT) scan indicated that gallstones that were seen on a recent ultrasound were not identified. There was suggestion of gallbladder wall thickening, and acute cholecystitis could not be ruled out. The note stated that as air in the bowel can mimic gallstones on ultrasound, a Magnetic Resonance Imaging (MRI) scan was advised. There was no CT evidence of pancreatitis. There was mild constipation noted. The patient was recommended for admission, so she could undergo a hepatobiliary iminodiacetic acid (HIDA) scan. The patient was also recommended to utilize Zofran as needed. She was also diagnosed with a urinary tract infection, and it was recommended that she continue antibiotics. The patient did undergo a HIDA scan, which did not reveal any biliary or cystic duct obstruction. It was recommended that the patient undergo an elective cholecystectomy. The patient on exam was noted to have slightly elevated liver enzymes, which continued to trend downward. The following day, after no significant adverse events, the patient was discharged in stable condition with instructions to follow-up.

The insurer has denied coverage for the inpatient hospital admission as not medically necessary. The denial was upheld.

According to current literature, a patient may be admitted for undiagnosed abdominal pain when there are peritoneal signs, hemodynamic instability, severe pain requiring acute inpatient management, surgery is needed that cannot be performed on an ambulatory basis or there is identification of etiology or finding that requires inpatient care. Within the documentation, the above was not noted. The patient was recommended for admission after laboratory and imaging suggested the possibility of acute cholecystitis. However, there was no documentation of why the patient could not have continued observation at a lower level of care. The documentation did not detail that the patient needed emergent surgery or that there were peritoneal signs present. Additionally, there was no evidence of hemodynamic instability or severe pain requiring acute inpatient management. The medical necessity is not substantiated.

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