Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute cholecystitis

Treatment: Inpatient admission

The insurer denied the inpatient admission. The denial was upheld.   

This is a female patient with a history of diverticulitis, gastroesophageal reflux disease (GERD) and bilateral hip surgery. She presented to the Emergency Department (ED) with complaints of severe abdominal pain located in the right upper quadrant with associated nausea and vomiting. Laboratory work up was performed that revealed an elevated white blood cell (WBC) count of 14.  An abdominal ultrasound was done that showed gallbladder filled with gallstones with no evidence of acute cholecystitis or biliary ductal dilation. Surgery consulted on the patient. The patient was made nothing by mouth (NPO) and intravenous (IV) fluids were administered. The patient underwent a laparoscopic cholecystectomy without complications. The patient was medically stabilized and discharged home with outpatient instructions. 

As per the patient's discharge summary, the patient had symptoms of biliary dyskinesia for several years, but always tested negative including a normal HIDA scan. This time, the patient presented to the hospital with severe right upper quadrant (RUQ) pain radiating to the back. As per the discharge summary, the patient had acute cholecystitis as confirmed by her clinical presentation and support of the patient's ultrasound. The patient underwent a definitive procedure and was discharged the following day.

According to the MCG Health Inpatient and Surgical care (24th edition) guidelines on Gall bladder or bile duct inflammation or stone ORG: M-555 (ISC), the goal length of stay is ambulatory. 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, acute cholecystitis, and/or obstruction of the gallbladder or bile duct. For those who have a calculus or obstruction of gallbladder or bile duct, the indication for inpatient admission is if the patient has hemodynamic instability, common bile duct obstruction diagnosed by imaging, vomiting that is severe or persistent, dehydration that is severe or persistent, severe pain requiring acute inpatient management, and/or bacteremia. 

Based on the review of the medical record, this patient did not have the clinical sign and symptoms for acute cholangitis and acute cholecystitis. The patient's ultrasound noted that the patient's gallbladder was filled with gallstones but had no evidence of acute cholecystitis or biliary ductal dilation. The patient was afebrile and vitals were stable. The patient presented with nausea but there was no documentation of severe and/or persistent vomiting. The patient was given abdominal rest with "nothing by mouth" and was provided intravenous fluids but did not present clinical signs of dehydration. After the cholecystectomy, the patient was noted to feel better. There was no documentation that the patient's pain was severe and required acute inpatient management. There was no clinical concern for bacteremia or infection that required antibiotics administration. The patient therefore did not meet the MCG guidelines criteria for acute inpatient admission. Based on the MCG guidelines criteria, the patient could have been admitted to an observation care for pain (e.g., biliary colic) that persisted despite emergency department treatment.  
The health plan acted reasonably with sound medical judgment and in the best interest of the patient.

The carrier denial of coverage for the inpatient hospital services is upheld.  The medical necessity is not substantiated.