Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cholelithiasis
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is upheld.

This is the case of an adult female who presented to the emergency department (ED); per triage note the patient presented with generalized abdominal pain and diarrhea. The patient was afebrile with stable vital signs. The ED provider noted the history of presenting to the ED because of abdominal pain in the right upper quadrant (RUQ) region for the past 2 days. The patient stated she was seen one month ago and was told she had gallstones and followed up with surgery and had surgery scheduled. On exam she had RUQ epigastric tenderness to palpation, non-distended without rebound or guarding. The plan was to admit. White Blood Cells (WBC) were 6.67, total bilirubin was 0.2, aspartate aminotransferase (AST) was 152, alanine transaminase (ALT) 78 and Alkaline phosphatase of 136. Sonogram revealed cholelithiasis with no definite secondary sonographic sign of acute cholecystitis. There was no gall bladder thickening or pericholecystic fluid noted. Cholelithiasis was noted with the largest stone being 2.7 millimeters (mm). The bile ducts were normal, and common bile duct (CBD) measured 6 mm.

Based upon the records, the acute inpatient hospital admission was not justified as this patient could have been managed as noted by the insurer in an ambulatory/observation setting as she had an uneventful laparoscopic cholecystectomy for cholelithiasis. She did not have a significantly elevated WBC and she did not have a fever. She did not have markedly abnormal liver function tests. She did merit having her gall bladder taken out and it had been planned for an elective laparoscopic cholecystectomy as an outpatient. She presented now with pain and was taken this time for the laparoscopic cholecystectomy. This could have been done in an ambulatory/observation setting.
 
This patient did not need to be admitted as she could have been managed with an outpatient/observation basis. She did not have any indication for acute inpatient admission. She did not have acute cholangitis and probably did not have acute cholecystitis but rather biliary colic. She was seen in the ED and surgery was done and she went home. She had an uneventful lap cholecystectomy - all of which should have been done in observation setting as noted by the insurer. She did not need an acute inpatient hospital admission. I therefore believe that the patient should have been cared for with an ambulatory observation setting. Furthermore, according to Milliman Care Guidelines (MCG) Inpatient and Surgical Care 26th 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. MCG also noted "that analysis of a cohort of 95,523 adult patients who underwent laparoscopic cholecystectomy within 10 days of presentation with acute cholecystitis found that 65% [percent] of the laparoscopic cholecystectomies were performed either the day of presentation (day 0) or the following day (day 1)."  Thus, ambulatory status would have been appropriate. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably, with sound medical judgment, and in the best interest of the patient. 

The medical necessity for the inpatient hospital admission is not substantiated.