Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute cholecystitis

Treatment is an inpatient admission 

The insurer denied coverage for an inpatient admission 
 
The denial is overturned

The patient with history of DVT (deep vein thrombosis) and multiple orthopedic procedures who presented to the ED (emergency department) from the rehab facility with complaints of abdominal pain. She had a negative murphy sign. She had elevated LFT's (liver function tests) with a sonogram showing 9.6 mm (millimeters) CBD (Common bile duct) and gallbladder wall thickening. She had multiple orthopedic injuries on her previous admission from an MVA (motor vehicle accident) and had a DVT, status post IVC (inferior vena cava) filter and is on Eliquis for anticoagulation. On admission her WBC (white blood cell count) was 5.7; Alkaline Phosphatase 635, AST (aspartate aminotransferase) 1053, ALT (alanine transaminase) 784, and a bilirubin of 3.2. She was afebrile with stable vital signs. Her abdomen was soft, nontender with dark yellow urine. The plan was NPO (nothing by mouth), GI (gastrointestinal) consult, Magnetic resonance cholangiopancreatography (MRCP), IV (intravenous) fluids, Lovenox, and pain control. CT (computed tomography) Angio revealed filling defect within subsegmental branch of the right lower lobe pulmonary artery.

Ultrasound showed common bile duct (CBD) not dilated or having a sonographic Murphy sign, and thickened gallbladder. The patient was found to have elevated LFT's and RUQ (right upper quadrant) showing acute cholecystitis likely with choledocholithiasis. The progress note indicated the patient had a subsegmental pulmonary emboli (PE) and as per surgery the patient should not be anticoagulated for possible emergent procedure for choledocholithiasis.

Gastroenterology (GI) saw the patient and noted that the patient was pending MRCP (Magnetic resonance cholangiopancreatography) and will likely need an Endoscopic retrograde cholangiopancreatography (ERCP). GI did note that the procedure may be technically challenging given the vertebral fractures. GI suspected that she passed a stone. WBC was 5.8; total bilirubin 3.2, Alkaline Phosphatase of 635, AST 1053, ALT was 784. Repeat labs showed Alt 1533, Alkaline Phosphatase of 809, AST 1339, and a total bilirubin of 6.1.

MRCP after arm splint removal indicated findings consistent with acute cholecystitis with a dilated CBD to 9 mm (millimeters).

The patient underwent a lap cholecystectomy and intraoperative cholangiogram (IOC). The gall bladder was noted to be significantly edematous consistent with acute cholecystitis. Path revealed acute cholecystitis and focal cholesterolosis with no stones in the common bile duct (CBD).

Post-operatively the patient was stable. The pain was well controlled, and she was tolerating her diet. She was continued on Lovenox with a discharge plan to continue long term anticoagulation.

MCG (Milliman Care Guidelines) General recovery care 26th edition Ambulatory surgery exception criteria GRG:CG-AEC (ISC GRG) 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 as she was being treated for DVT/PE (pulmonary embolism) with Eliquis which needed to be held. She did need to be treated with Lovenox until the surgery and she needed the evaluation and surgery given the markedly abnormal liver function tests. Thus, inpatient admission was warranted.

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

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 inpatient hospital admission is overturned. Medical Necessity is substantiated.