The patient presented to the emergency department (ED) with complaints of abdominal pain and concurrent fever. The patient has a medical history of sclerosing cholangitis as well as having had stents. The patient was imaged on admission for abdominal complaints and, while no abnormalities were noted within the abdomen, there was notation that the patient had infiltrate/atelectasis in the right lower lobe. The patient did not have nausea, vomiting or hematemesis and did not have cough. The patient did not have dyspnea and did not have dysuria. The patient is documented as having a fever of 105.3 on admission and had a lactate of 2.4 but remained hemodynamically stable. The inpatient stay is under review.

The health plan's determination is upheld. The inpatient stay was not medically necessary. The patient presented with abdominal pain and had incidentally noted RLL (right lower lobe) changes that could have been atelectasis or pneumonia. The patient did not have nausea, vomiting or hematemesis and did not have cough. The patient did not have dyspnea and did not have dysuria. The patient did have an elevated temperature at 105.3 as well as an increase in the lactate which does justify the diagnosis of sepsis. However, the patient did not have evidence of end organ damage and responded to measures enacted upon admission. The fever rapidly improved within hours of admission. I do not see a reason for an inpatient level of care based on the provided documentation. The patient could have been cared for at a lower level of care.