Diagnosis: Abdominal Pain
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld

This patient is a male who presented to the emergency department with the complaint of abdominal pain of two-days duration. Of note, he had undergone laparoscopic cholecystectomy for the condition of gallstone pancreatitis.

The patient's vital signs at the time of presentation were notable for mild tachycardia (heart rate 102 beats per minute). Examination revealed a tender abdomen. The white blood cell (WBC) count was elevated at 12.6 thousand (K). Alanine aminotransferase (ALT) and alkaline phosphatase (Alk Phos) were elevated with normal bilirubin. An abdominal computed tomography (CT) was obtained. A gastroenterology consultation was obtained.

The patient was initially treated with nothing by mouth (NPO) status, intravenous fluids and follow up lab data. Day two, the records indicate that the patient was clinically stable with normal vital signs. The patient was deemed stable for discharge from the hospital on day three.

The health plan rationale for denial of inpatient care was based on the Milliman Care Guidelines (MCG) Criteria 25th edition - Abdominal Pain, Undiagnosed.

No, the proposed inpatient hospital admission was not medically necessary.
In this case inpatient care was not medically necessary. The care and treatment provided during this time could have been rendered with an observation level of care and did not require an inpatient designation. This lower level of care would have provided for surgical assessment, intravenous fluid, follow up, labs, and overnight monitoring.

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
The health plan acted reasonably and with sound medical judgment. Acute inpatient hospitalization was not medically necessary for this patient. The medical records support that this patient could have been reasonably and safely monitored with an observational status.

This patient presented with abdominal pain. He was status post cholecystectomy for gallstone pancreatitis performed four days earlier. His evaluation with examination, lab data, and computed tomography (CT) scan identified no obvious indication for acute surgical intervention. There was pancreatic inflammation that was improved compared to a prior study. The patient was monitored and remained clinically stable during the period of monitoring.

This patient's clinical needs could have been satisfied with an observational level of care. This level of care would have provided for clinical assessment and monitoring as was performed.