Diagnosis: abdominal pain
Treatment; Inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld.

The patient is a man who presented with abdominal pain, nausea. At the time of presentation, the patient was without fever and vital signs showed elevated blood pressure and normal heart rate. He was tender in the abdomen diffusely. The white blood cell (WBC) count was slightly elevated at 10.5. The complete metabolic panel identified normal alkaline phosphatase, aspartate aminotransferase (AST) and alanine aminotransferase (ALT), and bilirubin. A computed tomography (CT) scan and abdominal ultrasound showed gallstones and findings of cholecystitis (thickened gallbladder wall).
He was admitted to the hospital and initially treated with intravenous (IV) fluid, antibiotics, and antiemetics.

An inpatient level of care was not medically necessary in this case. This patient presented to the hospital with abdominal pain, nausea. He was determined to have cholelithiasis/cholecystitis. There is no documentation of hemodynamic, pulmonary, neurological, or metabolic reason for an acute inpatient level of care. Additionally, there is no documentation of failure to achieve discharge criteria, conversion to open surgery, care for comorbidities, procedural complications, or any other condition requiring inpatient admission. The indication for cholecystectomy was established and surgery was performed 3 days later. Acute inpatient care was not medically necessary for this patient as the care and treatment provided could have been rendered at a lower level which would have provided for ED (emergency department) assessment, perioperative care and monitoring, provision of IV antibiotics and fluid, and overnight care.