Diagnosis: Digestive System/Gastrointestinal
Treatment: Inpatient hospital stay

Diagnosis: Digestive System/Gastrointestinal-Abdominal Pain/Gallbladder Problem.
Treatment: Inpatient hospital stay.
The health plan denied the inpatient stay as not medically necessary.
The reviewer has upheld in whole the health plan's determination.

The patient presented to the hospital emergency department (ED) on with upper abdominal pain and vomiting of 1-day duration. She had recently had a positive Covid diagnosis. At the time of presentation, the patient was without fever and vital signs showed a heart rate of 75/minute and blood pressure of 157/101 millimeters of mercury (mmHg). She was tender in the upper abdomen. The white blood cell count was 11 thousand(K). The complete metabolic panel identified normal aspartate aminotransferase (AST), alanine aminotransferase (ALT), and Bilirubin. A computed tomography (CT) scan showed cholelithiasis and findings of cholecystitis.
She was initially treated with intravenous (IV) fluid and antiemetics. Surgical consultation was obtained. The surgical service decided that urgent surgery was not required, and the patient was treated with antibiotics with plans for interval cholecystectomy.
The patient tolerated oral intake. She was discharged from the inpatient setting with instructions for outpatient surgical follow up.

An inpatient level of care was not medically necessary in this case. This patient presented to the ED with abdominal pain. Evaluation identified gallstones and findings of cholecystitis. She was hemodynamically stable at the time of presentation. The WBC count was slightly elevated at 11K. The patient had recently had Covid infection. The surgical service advised that urgent cholecystectomy was not required. The patient remained hemodynamically stable during the period of monitoring. A lower level of care status would have allowed for overnight monitoring, confirmation of clinical stability, and diet advancement.
A lower level of care would have been appropriate. There is no documentation of hemodynamic, pulmonary, neurological, or metabolic reason for an acute inpatient level of care at the time of presentation. This lower level of care would have been consistent with generally accepted standards of care. This would have allowed for surgical assessment, treatment with IV fluid and antibiotics, and arrangements for outpatient follow up.