202302-159363
2023
Healthfirst Inc.
Medicaid
Digestive System/ Gastrointestinal
Inpatient Hospital
Medical necessity
Upheld
Case Summary
Diagnosis: Abdominal Pain
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Stay.
The determination is upheld.
This is a female patient with a medical history of anemia. She presented to the emergency department with right upper quadrant abdominal pain and back pain, vomiting, and difficulty walking. The vital signs were unremarkable. The physical examination was notable for right upper quadrant and epigastric tenderness, and positive Murphy's sign. A right upper quadrant ultrasound showed cholelithiasis with slightly thickened gallbladder wall, normal caliber bile ducts, negative Murphy's sign, heterogeneity of hepatic parenchyma, 1.2 x 1.2 x 1.0 centimeter (cm) echogenic mass in the left lobe of the liver which may be incidental hemangioma, and poorly visualized pancreas.
She was treated with intravenous Toradol, Zofran, and fluids. She was made nil per os. A pediatric surgery consultation recommended monitoring the vital signs, magnetic resonance imaging to evaluate the liver mass, and admission to pediatrics. She was in no acute distress, with no abdominal pain, back pain, and nausea; she was advanced to a regular diet. A gastroenterology consultation noted concern for autoimmune hepatitis given elevated transaminases and globulins, unlikely choledocholithiasis, and downtrending transaminases with normal coagulation labs; the recommendation was blood tests to assess for liver disease, possible cholecystectomy at some point, liver biopsy when possible, and outpatient follow-up. She was discharged. At issue is the medical necessity for the inpatient level of care.
The inpatient level of care was not medically necessary. The patient presented with right upper quadrant abdominal and back pain, elevated transaminases, gallstones, and possible cholecystitis; choledocholithiasis was not established. Magnetic resonance imaging with cholangiopancreatography was planned but deferred to outpatient, but there was no hemodynamic instability, ascending cholangitis, hepatic abscess, active gastrointestinal bleeding, peritonitis, fistula, or sepsis; a cholecystectomy was not performed during the stay, so there were no risk for postoperative complications such as postoperative pneumonia, bile leak, and bleeding. Lab workup for liver disease was appropriately performed, and transaminases trended downward; the bilirubin normalized. The care provided, including monitoring, labs, imaging, and specialist consultations, could have been performed in sequence after presentation, without the need for the inpatient level of care. For these reasons, the inpatient level of care is not supported, and the care provided could have been provided at a lower level of care.