Appeal type: Medical necessity
Decision: Upheld

Diagnosis: right upper/lower abdominal pain status-post laparoscopic cholecystectomy
Treatment: Inpatient admission 
The insurer denied coverage for: Inpatient admission
The denial is: Upheld
This is the case of an adult patient who presented to the Emergency Department (ED) for complaints of abdominal pain. As per the triage note the patient was afebrile with a Blood pressure (BP) of 170/90. The patient complained of abdominal pain for 3 days and was status-post surgery for small bowel obstruction (SBO) performed a week earlier. The patient reported nausea without vomiting. The abdomen was soft and non-distended. 

Per the ED provider note the patient was complaining of abdominal pain and stated that they had a gastric surgery in 2022, and just 8 days ago and had small bowel obstruction (SBO) and surgical intervention with lysis of adhesions. The patient was doing well at home until Saturday when the patient started to have right upper/lower abdominal pain without vomiting. The patient was passing stool. The exam revealed tender to palpation in the right upper and lower abdomen. The abdomen was soft. A little over a week ago the patient had a diagnostic laparoscopy and extensive lysis of adhesions for small bowel (SB) performed by the same provider. 

Computed tomography (CT) of the abdomen showed prominent inflammation without gross evidence for free intraperitoneal air or contrast extravasation. Oral contrast was demonstrated within the small bowel and colon without evidence of bowel obstruction. Sonogram of the RUQ showed normal liver with distended gallbladder. The gall bladder wall had upper limits of normal in thickness. There was trace pericholecystic fluid. There was no cholelithiasis and no sonographic Murphy's sign. The common bile duct (CBD) was normal. The plan was empiric antibiotics and hepatobiliary iminodiacetic acid (HIDA) scan.

HIDA scan indicated normal gall bladder and no evidence of acute cholecystitis. There was no evidence of significant biliary obstruction. There was reduced gallbladder ejection fraction of 16% compatible with biliary dyskinesia. Medical clearance was obtained, and patient was taken to the operating room. 

The patient was taken to the operating room and underwent lap cholecystectomy and intraoperative endoscopy with the findings of acute on chronic acalculous cholecystitis and 1.2 marginal ulcer. 

Postoperative day one patient was doing well, tolerating diet, pain managed and was discharged to home. 

Based upon the records the reviewer agrees that inpatient admission was not justified as this patient should have been managed as noted by the insurer in an ambulatory/observation setting as the patient had an uneventful laparoscopic cholecystectomy for biliary dyskinesia. The patient did not have acute cholecystitis as noted on the hepatobiliary iminodiacetic acid (HIDA) scan but rather biliary dyskinesia. The patient was then kept in-house to have what could have been an elective cholecystectomy as an out-patient especially since the labs were normal and the patient had recently undergone surgery for small bowel obstruction (SBO) and lysis of adhesions. The patient did not have acute cholangitis, was not septic, did not have elevated white blood cell count (WBC), did not have a fever, and the patient did not have elevated liver function tests. Furthermore, according to Milliman Care Guidelines (MCG) Inpatient and Surgical Care 27th Edition cholecystectomy by laparoscopy the operative status criteria is ambulatory. Thus, this patient should have been managed without an inpatient acute admission for this procedure. 

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