This patient presented to the hospital with symptoms of left sided abdominal pain of 2-days duration. The patient had recently undergone treatment for cholelithiasis and choledocholithiasis with cholecystectomy and endoscopic retrograde cholangiopancreatography (ERCP)/sphincterotomy/stent placement. The patient had a surgical drain in place at the time of emergency department (ED) presentation.Computed tomography (CT) scan showed post-surgical changes of cholecystectomy and stent placement. Initial treatment included intravenous (IV) fluid and pain medications. The existing surgical drain was removed. The progress notes document normal vital signs. The patient was started on a diet. The patient's pain resolved and the patient was discharged from the inpatient setting. The health plan's determination is upheld.

Based on the submitted clinical documentation, an inpatient level of care was not medically necessary in this case. The patient was 5-days status/post (s/p) laparoscopic cholecystectomy and subsequent ERCP/stent placement for common bile duct (CBD) stones. Vital signs and lab data did not identify unexpected pathology at the time of presentation. The vital signs remained normal during the period of hospitalization until discharge. The submitted medical records support that the patient could have been managed at a lower level of care, which would have provided for the necessary evaluation in the ED and follow up care.
Inpatient level of care was not medically necessary. The patient was clinically stable at the time of presentation and remained so during the period of overnight monitoring as supported by the corresponding medical records and progress notes.