Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute cholecystitis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission. The denial was reversed.

This patient is a male with no past medical history who presented to the emergency department (ED) with complaints of abdominal pain for 2 weeks.  He denied nausea, vomiting, or diarrhea. He presented with stable vital signs and was afebrile. He was scheduled for esophagogastroduodenoscopy (EGD) today for the pain that he was having for 2 weeks worsened. On exam his abdomen was soft non-distended with mild epigastric tenderness without rebound or guarding. The differential diagnosis was pancreatitis acute cholecystitis. His WBC was 8.4. Total bilirubin was elevated at 2.3, AST was elevated at 60, Alk Phos was elevated at 187 and ALT was normal at 33. CT of the abdomen reported revealed multiple cholelithiasis with gallbladder wall thickening with pericholecystic fat stranding which may represent acute cholecystitis. The impression was acute cholecystitis with no biliary ductal dilation or filling defects in the biliary tree. The patient was admitted and made nothing by mouth (NPO) with IV antibiotics. The patient was admitted with the diagnosis of acute cholecystitis as per the note. The plan was laparoscopic cholecystectomy in the a.m. Gastroenterology (GI) saw the patient in consultation MRCP was done and revealed acute cholecystitis with no biliary ductal dilation.

Patient underwent an uneventful lap cholecystectomy with the operative note indicating the patient underwent an MRCP which was negative with the patient likely passing a stone through the biliary system. The imaging was consistent with acute cholecystitis. The op note indicated the patient had extensive stones and extensive edema around the gall bladder consistent with acute cholecystitis. A Jackson-Pratt (JP) drain was placed at the time of surgery. Pathology results revealed acute cholecystitis with ulceration and transmural acute and chronic inflammation.

Progress note by surgery noted the patient s/p lap cholecystectomy and was doing well. He was discharged with a JP drain in place and a 7 day course of oral antibiotics and pain medications. According to MCG Health Inpatient and Surgical care-23rd edition Gallbladder or bile duct inflammation or stone ORG: M-555 (ISC), clinical indications for admission to inpatient care may include patients with 1 or more symptoms.

Evidence of common bile duct disease indicated by 1 or more of the following: Total serum bilirubin level greater than or equal to 2 mg/dL (34 micromoles/L), Liver function test (alkaline phosphatase (ALP), r-glutamyl transferase (GGT), aspartate aminotransferase (AST), or alanine aminotransferase (ALT)) greater than 1.5 times the upper limit of normal, Hepatobiliary imaging showing biliary dilatation or evidence of etiology (e.g., stricture, stone, previously placed stent); Common bile duct obstruction diagnosed (e.g., by imaging), Vomiting that is severe or persistent, Dehydration that is severe or persistent,  Hemodynamic instability, Severe pain requiring acute inpatient management, Signs of intestinal obstruction or peritonitis, Bacteremia,  Percutaneous or open drainage (e.g., abscess, biliary tract) procedures, Other condition, treatment or monitoring requiring inpatient admission.

This patient did have signs and symptoms for acute cholecystitis with abnormal CT and MRCP and elevated total bilirubin of 2.3 on admission. He therefore had indications for acute inpatient admission and for lap cholecystectomy. Thus, the patient did meet criteria for admission and could not have been treated with Observation level of care.

The health care plan did not act reasonably and with sound medical judgment and in the best interest of this patient. 
Based on the above, the medical necessity for the inpatient admission is substantiated. The insurer's denial is reversed.