Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic Cholecystitis, Cholelithiasis and Umbilical Hernia. 
Treatment: Inpatient Admission. 

The insurer denied coverage for inpatient admission. 

The denial is upheld. 

This is the case of an adult female with history of cholecystitis who was directly admitted to the hospital a laparoscopic cholecystectomy. She had initially been seen in the emergency department (ED) and subsequently refused admission but returned after 72 hours with recurrent symptoms and was admitted directly for surgery. The patient was taken to the operating room. As per the operative note, she underwent an uneventful lap cholecystectomy and repair of umbilical hernia. Pathology revealed chronic cholecystitis and cholelithiasis and umbilical hernia sac. The anesthesia post op note indicated the patient was cleared for discharge. The Nursing note indicated the patient was in pain and was given Percocet. The progress note by the physician assistant noted that the patient complained of pain in the surgical sites. She was afebrile with stable vital signs. The patient was on a regular diet and the plan was for the patient to be discharged. 

According to the guidelines of MCG (Milliman Care Guidelines) Health Inpatient and Surgical Care - 25th edition Gall bladder or bile duct inflammation or stone ORG: M-555 (ISC), patients may be discharged to a lower level of care (either later than or sooner than the goal) when it is appropriate for their clinical status and care needs. The clinical indications for admission to inpatient care may include patients with 1 or more of the following:  Acute cholangitis as indicated by ALL of the following: Systemic signs of inflammation indicated by 1 or more of the following: fever, C-reactive protein level greater than 10 mg/L [milligram per liter]...Vomiting that is severe or persistent, Dehydration that is severe or persistent,  Severe pain requiring acute inpatient management, Bacteremia. 

In addition, according to MCG Health Inpatient and Surgical Care 25th Edition Hernia Repair (Non-Hiatal) ORG: S-1305 (ISC), the operative status criteria is ambulatory. MCG also noted extended inpatient care may be warranted in certain situations as defined by Minimal (a few hours to 1 day), Brief (1 to 3 days), Moderate (4 to 7 days), and Prolonged (more than 7 days). Inpatient stay may be needed for: Emergent surgery for patient with strangulated hernia, or other evidence of ischemia or infarction of hernia contents, may require continued inpatient care, anticipate parenteral treatments (e.g., antibiotics), close monitoring, and repeat laboratory ...iven the above, inpatient admission was not warranted for this patient as she did not have any of the indications above for an extended stay rather than an ambulatory status for the incidental hernia repair. 

The patient was admitted, had the surgery and went home - all of which could have been done in an ambulatory setting. The patient did not meet criteria for an acute admission for acute cholecystitis as she was admitted directly after returning 72 hours later from an emergency department (ED) visit. Based upon the records, this patient could have been managed as noted by the insurer in an ambulatory/observation setting as she had an uneventful laparoscopic cholecystectomy. 

The admission was not justified at the inpatient admission level as the patient should have been managed in an observation setting. 

The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The insurer's denial of coverage for the inpatient admission is upheld. Medical necessity is not substantiated.