Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute Cholecystitis

Treatment: Full Hospital Admission

The insurer denied coverage for full hospital admission.

The denial is overturned.

This is the case of a male with past medical history of diabetes, hypertension gastroesophageal reflux disease (GERD), gallstones, pyelonephritis and morbid obesity.  He presented to the Emergency Department (ED) with complaints of abdominal pain. The patient presentation was afebrile with stable vital signs.  As per the ED provider note the patient presented with severe right upper quadrant (RUQ) pain that was unrelieved with Tylenol.  The patient denied fevers, chills. The patient had a known history of gallstones and was scheduled for a cholecystectomy.  The patient had a past medical history of gastric sleeve.  Exam revealed the abdomen to be soft with right upper quadrant tenderness with positive Murphy's sign.  White blood cell (WBC) count was 6.69. Sonogram revealed cholelithiasis with mild wall thickening and a positive Murphy's sign. General surgery was called.  General surgery noted the history and also noted aspartate transaminase (AST) of 443 and alanine aminotransferase (ALT) of 278.  The assessment was acute cholecystitis with plan to the operating room.  Progress note indicated the patient refused Magnetic resonance cholangiopancreatography (MRCP) despite liver function test (LFT) results.  Therefore, the plan was lap cholecystectomy and intraoperative cholangiogram (IOC).

Gastroenterology (GI) consult was obtained who noted the history and the fact that the patient had bilirubin that rose from normal to 4 with marked worsening of his liver function tests.  The provider noted a high suspicion for choledocholithiasis.  The patient refused MRCP due to claustrophobia.  The case was discussed with the surgeon and the plan was lap cholecystectomy and IOC.
The patient was taken to the operating room and underwent laparoscopic cholecystectomy, lysis of adhesions and attempted cholangiogram. Findings included acute calculous cholecystitis, small caliber cystic duct precluding passage of the cholangiogram catheter and adhesions from previous surgery.

Post operatively, the patient did well. Progress note indicated the patient felt overall better.  The liver function tests (LFTS's) were trending down.  The plan was full liquid diet and discontinue antibiotics and to be discharged with repeat LFT as outpatient.

The insurer denied coverage for the full hospital admission as not medically necessary.  

Based upon the records, this reviewer does feel that the full hospital admission was justified as this patient did have acute cholecystitis and markedly elevated and abnormal liver function tests.  He was admitted and should have had an MRCP but refused and therefore was taken to the Operating Room for a lap cholecystectomy with attempted IOC.  Post operatively he did better and was discharged. However, he needed to be admitted with significantly elevated liver function tests as he met guidelines of MCG for gall bladder or bile duct inflammation.  According to the guidelines of  MCG Health Inpatient and Surgical care- 25th edition Gall bladder or Bile Duct Inflammation or Stone ORG: M-555 (ISC) the goal length of stay is ambulatory or 2 days and assumes optimal recovery, decision making, and care.  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 inpatient hospital admission level was medically necessary. The patient did have acute cholecystitis/ cholangitis and indication for an inpatient admission due to the need for intravenous (IV) antibiotics and potential for MRCP due to potential choledocholithiasis with markedly abnormal liver function tests.  Based upon these findings the health care plan did not act reasonably and with sound medical judgment.  

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