Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute Cholecystitis
Treatment: Full Hospital Admission
The insurer denied the full hospital admission. 
The denial is upheld.

The patient is a female who presented with epigastric pain and nausea and vomiting. The pain was radiating to her back. Her comorbidities included rheumatoid arthritis, diabetes, and hypertension. The patient had tried Pepcid but this led to vomiting. Her vital signs in the emergency room (ER) demonstrated hypertension without other abnormalities. The patient was noted to have significant right upper quadrant tenderness. Her liver function tests (LFT's) were acceptable. The ultrasound demonstrated gallbladder wall thickening and edema with biliary sludge versus stone and was interpreted as possible early acute cholecystitis. The patient was hospitalized and planned for surgery the next day. The patient was taken for laparoscopic cholecystectomy which was performed without complication. The patient was monitored overnight and discharged home on the day after surgery. Pathology demonstrated chronic calculous cholecystitis with cholelithiasis.

The health plan in its determination of medical necessity acted reasonably, with sound medical judgement and in the best interest of this patient.

The patient's admission was not medically necessary at the inpatient level of care for the entire admission. According to the Milliman Care Guidelines (MCG) guidelines inpatient admission is indicated for acute cholangitis, acute cholecystitis when cholecystectomy is not anticipated, and for calculous or obstruction of the gallbladder with certain complications. The patient does not meet criteria for acute cholangitis as this requires systemic signs of inflammation and evidence of common bile duct disease. The patient does not meet criteria for acute cholecystitis with signs of systemic inflammation or where cholecystectomy is not anticipated. The patient did not have fever, C-reactive protein (CRP) elevation or white blood cell count elevation.

The patient does not meet criteria for calculous or obstruction of the gallbladder or bile duct with hemodynamic instability, common bile duct obstruction, vomiting that is severe or persistent, severe pain requiring acute inpatient management, bacteremia. The patient also does not meet MCG criteria for undiagnosed abdominal pain which requires: Hemodynamic instability, Severe Pain, Peritoneal signs, identification of an etiology that requires inpatient care, nothing by mouth (NPO) status greater than (>) 24 hours requiring significant intravenous (IV) fluid support, suspected toxic megacolon, bacteremia, procedure that cannot be performed on ambulatory basis, parenteral nutrition. The documentation does not suggest that the patient's care could not have been performed at a lower level of care. There is no evidence that additional complex testing or therapy other than the procedure was performed. There is no documentation that the treating team identified conditions or problems specific to the patient that would have required inpatient care. The provided documentation does not support the medical necessity of inpatient level of care.

The health plan's determination of medical necessity is upheld in whole.