Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Common Duct Obstruction
Treatment: Full hospital admission
The insurer denied coverage for the full hospital admission.
The denial is overturned.

This is the case of an adult female with history of an open appendectomy in the past who presented to the Emergency Department (ED) with complaints of intermittent episodes of right upper quadrant (RUQ) pain associated with nausea and vomiting. She was afebrile with stable vital signs. She has been gluten free and ate a pretzel the day of admission and has had pain since then. She made herself vomit to see if it would make her feel better. She has had similar symptoms in the past which alleviated on their own and she did not seek medical attention. The pain was noted as 8/10. On exam, the abdomen was soft non-distended with RUQ and epigastric tenderness. The plan was pain medications, sonogram of the abdomen, labs and Zosyn. The amylase was 49; white blood cells (WBC) was 11.8 with alkaline phosphatase of 53, aspartate transaminase (AST) 484, alanine transaminase (ALT) 285 and total bilirubin of 1.4.

The ultrasound report indicated the gallbladder was distended with gallstones with a non-mobile impacted stone in the gallbladder neck. There was no evidence of gallbladder wall thickening or pericholecystic fluid. The common duct was normal in caliber measuring 4 mm (millimeters). A sonographic Murphy's sign was not elicited. The impression was cholelithiasis. The plan was to consult general surgery and admit for possible cholecystitis. 

Surgery noted the patient's history of intermittent RUQ abdominal pain with nausea and vomiting which has not improved. The plan was repeat liver function tests (LFTs) and magnetic resonance cholangiopancreatography (MRCP). MRCP revealed non dilated common bile duct with a suggestion of a non-obstructing distal ductal 2 mm filling defect which may reflect a non-obstructing stone. Gastroenterology (GI) was consulted for choledocholithiasis and noted the patient denied history of fever, chills, jaundice or change in the color of her stool. The provider noted that the patient had an MRCP in the ED which showed common bile duct stones. 

The patient denied fever, chills. The pain had resolved. MRCP showed gallstone with distal common bile duct (CBD) obstruction. The patient underwent endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy by GI. The patient was taken to the operating room and underwent an uneventful laparoscopic cholecystectomy. Pathology revealed chronic cholecystitis and cholelithiasis. The patient tolerated the procedure and with pain well controlled and she was able to tolerate diet. She was later discharged.

She met 26th edition MCG criteria under Gallbladder or bile duct inflammation or stone (M-555-RRG) for admission with calculus or obstruction of gallbladder and severe pain requiring inpatient management. Although this was not acute cholecystitis, she did have evidence of common duct obstruction on MRCP requiring ERCP and sphincterotomy and therefore did need an acute inpatient admission. 

Milliman Care Guidelines (MCG) General recovery care 26th edition Ambulatory surgery exception criteria notes that potentially ambulatory procedure or surgery warrants inpatient care due to 1 or more of the following: Inpatient care needed for clinically significant preoperative disease or condition; Complex surgical approach or situation anticipated; Procedure is not low risk and patient at high anesthetic risk; Presence of drug-related risk; Inadequate outpatient care situation; Postoperative event, condition, or finding that warrants inpatient stay. Given the above, the patient did warrant inpatient status for the choledocholithiasis requiring ERCP, sphincterotomy and lap cholecystectomy. These liver function tests were not improving by the following morning after admission and thus the patient required a procedure as noted by GI.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for full hospital admission is overturned. Medical Necessity is substantiated.