202012-133071
2020
United Healthcare Plan of New York
HMO
Digestive System/ Gastrointestinal
Inpatient Hospital
Medical necessity
Upheld
Case Summary
Diagnosis: Abdominal Pain.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay. The determination is upheld.
The patient has a past medical history (PMHx) significant for hypertension (HTN) and gastroesophageal reflux disease (GERD), who presented to the emergency room (ER) with complaints of abdominal pain. Her vital signs were stable. Lab results revealed leukocytosis with an elevated white blood cell count (WBC). An ultrasound revealed gallstones and common bile duct (CBD) dilatation. A computed tomography (CT) scan revealed gallbladder wall thickening. The patient was made nothing by mouth (NPO) and was supported with intravenous fluids (IVF) and pain medication. A hepatobiliary iminodiacetic acid (HIDA) scan was ordered, which was negative. The patient had improvement in the pain and was transitioned to by mouth (PO) and PO pain medication and discharged home. At issue is the medical necessity of an inpatient stay.
The inpatient stay was not medically necessary.
The patient presented with symptomatic cholelithiasis. She was ruled out for acute cholecystitis with a negative HIDA scan and was discharged home. There was no decision to proceed with surgery. The patient met standard discharge criteria with stable vital signs, ability to tolerate PO and PO pain medications within a 23-hour period. Care could have been provided at a lower level than inpatient.