201908-120403
2019
Fidelis Care New York
Medicaid
Digestive System/ Gastrointestinal
Inpatient Hospital
Medical necessity
Upheld
Case Summary
Diagnosis: Abdominal pain
Treatment: Inpatient admission
The proposed acute level inpatient care for the management of acute cholangitis and gram negative bacteremia was not medically necessary.
The patient underwent ERCP and biliary stent exchange at the outside hospital a day prior for the management of biliary stricture secondary to primary sclerosing cholangitis (PSC). He was discharged from the facility on Cipro, by mouth (PO), for five days, and Fentanyl patch. He presented to the ED with severe abdominal pain, subjective fever and chills, and was diagnosed with ascending cholangitis and gram negative bacteremia secondary to E.coli. He was hemodynamically stable in the ED and had a low grade fever of 99.0F which resolved after he was treated with broad spectrum antibiotics. His abdominal pain was controlled with IV morphine and the nausea was controlled with IV Zosyn. He was seen by GI and the recommendation was transfer the patient to the tertiary care where the ERCP was done, for further management of ascending cholangitis possibly due to occluded biliary stent. The tertiary center was contacted and they accepted the patient for transfer. Given this clinical scenario, and the fact, that the patient remained hemodynamically stable and afebrile throughout the clinical course and did not require surgical intervention, he could have been safely and appropriately managed at the lower level of care during his hospital say.