Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute Cholecystitis with Gangrenous Changes of the Gall Bladder
Treatment: Inpatient Stay
The insurer denied the inpatient stay.
The health plan's determination is overturned.

The patient is a male who presented to the hospital emergency department (ED) with abdominal pain of 1-day duration. Comorbid health conditions included atrial fibrillation on anticoagulation with Eliquis, and ulcerative colitis. At the time of presentation, the patient had a normal temperature. The heart rate was 71 beats per minute and blood pressure was 160/83 millimeters of mercury (mmHg). He had a tender right upper quadrant. The white blood cell count (WBC) was elevated to 10.7. The complete metabolic panel identified normal bilirubin and serum transaminases. The ultrasound showed gallbladder stones and a sonographic Murphy's sign consistent with acute cholecystitis. The computed tomography (CT) scan that also showed a distended gallbladder.
He was admitted to the hospital and initially treated with intravenous (IV) fluids, antibiotics, and antiemetics. The anticoagulants were held. A cardiology consultation was requested due to his history of atrial fibrillation and ongoing anticoagulation. He was treated with laparoscopic cholecystectomy. The operative dictation and the anesthetic record describe an inflamed and edematous gallbladder with gangrenous changes involving the gallbladder fundus.
The patient was treated with post-surgical monitoring, IV fluids, IV analgesia, and antiemetics. The laboratory data showed elevation of bilirubin, aspartate aminotransferase (AST) and alanine aminotransferase (ALT). The diet was advanced following surgery. The reported pain level was 9 out of 10 for which he was treated with parenteral analgesia. The Eliquis was resumed. The patient was stable, the pain level was improved, and he was discharged from the inpatient setting. Short term follow up was arranged.

The patient presented with acute cholecystitis and this diagnosis was confirmed by presurgical imaging, lab data (elevated WBC count) and intra-operative findings. Additionally, he had the diagnosis of atrial fibrillation treated with anticoagulation. This necessitated cardiology consultation prior to surgery and discontinuation of anticoagulation with normalization of coagulation status. He did undergo the surgical procedure in a timely manner and was found to have acute cholecystitis with gangrenous changes of the gallbladder. He required post-surgical antibiotics and post-surgical analgesia for a reported pain level of 9 out of 10.
General guidelines support that inpatient care is indicated when there is right upper quadrant pain, AND systemic signs of inflammation (fever, C-reactive protein greater than (>) 10, WBC count > 10). Inpatient admission is also indicated for acute cholangitis, common bile duct obstruction, vomiting that is severe or persistent, dehydration that is severe or persistent, hemodynamic instability, severe pain requiring acute inpatient management, signs of intestinal obstruction, bacteremia, need for percutaneous or open procedures, or other condition that requires inpatient admission.
In this case, the patient had acute cholecystitis and leukocytosis > 10. He also had comorbid disease that increased the intensity of service and required presurgical cardiology consultation and discontinuation of anticoagulation. He required acute surgical management, perioperative parenteral antibiotics, and the coordinated care of the surgical and cardiology teams as detailed above to justify an inpatient level of care. His condition did satisfy generally accepted guidelines for inpatient admission during this time.

The health plan's determination is overturned in whole.