CLINICAL SUMMARY:
A 29-year-old male patient with no significant past medical history arrived at the Emergency Department with ongoing abdominal pain, cramping and tenderness in the left upper quadrant and epigastric region. This patient presented with a weight of 523 pounds, a BMI of 87 and labs as follows: WBC 12.07, ANC 9.34, Hgb 13.4, PLT 300, Na 135, K 3.9, BUN 11, Cr 0.90, Glucose 132, HbA1c 6.3, CRP 1.5 and Lipase 24. Additional liver panel testing revealed elevated liver enzymes as follows: AST 154, ALT 102, ALP 228 and TSB 0.7. The patient was admitted, and general surgery was consulted. Doctors were unable to obtain a CT scan due to weight limitations, but an ultrasound showed cholelithiasis with mild inflammation. The surgeon did not recommend surgery, and the patient was treated conservatively with IV fluids, IV Unasyn, IV ceftriaxone and pain control with IV morphine x 3, PO Norco x 2, IV Zofran and IV Protonix. The hospital course was complicated by hypertension, with systolic pressure up to the 160s and prediabetes.
Over the two-day stay, the patient began to feel better symptomatically, and his diet advanced gradually. His white count normalized, and transaminases improved. IV fluid was discontinued while he remained on IV Unasyn. The patient continued to receive IV morphine for pain management during the stay, and his elevated blood pressure was addressed with dose adjustment of amlodipine and an addition of lisinopril. The medical record also indicates that the patient could benefit from metformin, however, this medication was not started in case a cholecystectomy was warranted post discharge upon follow up with the surgeon. The patient was discharged on day three with recommendations for outpatient follow-up regarding the patient’s blood pressure and a sleep test for sleep apnea assessment prior to a possible elective laparoscopic/robotic-assisted cholecystectomy.
INPATIENT STAY DENIAL
INPATIENT STAY DENIALThe commercial payer argued that there was a lack of medical necessity and denied the two-day inpatient stay. The insurance carrier stated that the case did not meet criteria guidelines, referring to a lack of documentation to support common bile duct stone or dilation. The patient’s records also did not show a bilirubin test of 1.7 or higher, and observation level of care (LOC) was approved based on InterQual guidelines.
THE APPRISEMD PROCESS
THE APPRISEMD PROCESSAn AppriseMD physician advisor conducted a peer-to-peer discussion with the commercial insurance medical director regarding the denial involving the 29-year-old patient with a history of morbid obesity who presented for evaluation of abdominal pain. The AppriseMD physician advisor highlighted the fact that the treating physician suspected acute cholecystitis and started initial treatment with IV fluids, IV Unasyn and consulted with a general surgeon. The physician advisor reasoned that inpatient LOC was appropriately recommended based upon the comorbid conditions and high-risk surgical status of someone with profound obesity. The physician advisor also reminded the payer that the patient did not require operative intervention during this hospitalization, despite being at a high pre-operative risk due to comorbidities. This discussion included an additional commentary by the physician advisor centering around the medical management of significant comorbid conditions specifically relating to the patient’s weight with a BMI greater than 80. The payer medical director ultimately approved the inpatient status admission based upon the patient’s presentation and comorbid conditions, as well as medical and supportive care that extended over two days.