Diagnosis: Digestive System/ Gastrointestinal.
Treatment: Inpatient Hospital.
The insurer denied: Inpatient stay.
The denial is upheld in whole.

The patient is a female who presented to the hospital emergency department (ED) with severe epigastric and right upper abdominal pain, nausea and vomiting. Comorbid health conditions included diabetes, renal cell cancer, obesity, and hypertension. She was hemodynamically stable at the time of presentation. She was tender in the epigastrium. The white blood cell (WBC) count was 9 thousand (K). Ultrasound identified gallstones and a minimally thickened gallbladder wall. The complete metabolic panel identified normal serum transaminases. Bilirubin was normal. She was initially treated with intravenous (IV) fluid and antiemetics. Surgical consultation was obtained. The surgical consultation indicates that the diagnosis was that of symptomatic cholelithiasis rather than acute cholecystitis.
Her pain improved, vitals remained normal, and the diet was advanced. The patient remained clinically stable and was discharged from the inpatient setting with instructions to obtain an outpatient hepatobiliary iminodiacetic acid (HIDA) scan.
The subject under review is the medical necessity for the inpatient admission.

The health plan's determination is upheld, in whole.

Inpatient admission was not medically necessary in this case. This is a patient with diabetes, a history of renal cell cancer, obesity, and hypertension who presented to the ED with cholelithiasis/cholecystitis. The evaluation identified gallstones and normal serum chemistries. She was hemodynamically stable at the time of presentation. Cholecystectomy was indicated based on the ED evaluation. The surgical notes include alternative diagnoses (symptomatic cholelithiasis rather than acute cholecystitis) for this patient with upper abdominal pain, nausea, vomiting, and gallstones. There is no documentation of hemodynamic, pulmonary, neurological, or metabolic reason for an acute inpatient level of care at the time of presentation.
There is no documentation of failure to achieve discharge criteria, performance of surgery, care for comorbidities that required inpatient care, procedural complications, or any other condition requiring inpatient admission. Acute inpatient care was not medically necessary for this patient as the care and treatment provided could have been rendered at a lower level of care status.

The Milliman Care Guidelines (MCG)-Gallbladder or Bile Duct Inflammation, 23rd edition were reviewed. These MCG state that the goal length of stay is ambulatory, but that extended stay may be required in the setting of failure to achieve discharge status, systemic infection, care for comorbidities or complications of the procedure, or other condition that requires inpatient admission.
In this case, none of these indications existed to justify an inpatient level of care.