Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Inflammation of Gallbladder
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is overturned.

The patient is an adult male. He presented to the hospital with abdominal pain, nausea, and vomiting of several days' duration.
The patient's vital signs were normal. He was tender in the right upper abdomen and jaundiced on exam. Aspartate aminotransferase (AST) and alanine aminotransferase (ALT)
were elevated at 357 and 455, respectively. Bilirubin was elevated at 6.6. Ultrasound revealed findings of gallstones, biliary ductal dilatation of 8 millimeters, and a thickened gallbladder wall consistent with cholecystitis. The patient was initially admitted to the hospital with the diagnosis of acute cholecystitis and choledocholithiasis. He was treated with intravenous fluid, intravenous antibiotics, nothing by mouth status, pain medications, and serial examination. The bilirubin value was further elevated the next day. On the next day, the patient was evaluated with magnetic resonance cholangiopancreatogram
(MRCP) that showed a distal common duct stone. Gastroenterology consultation was obtained, and the patient underwent endoscopic retrograde cholangiopancreatography (ERCP) on day #3 (Number 3). This evaluation identified an edematous major papilla with a laceration consistent with passage of a stone. A biliary sphincterotomy was performed, but the endoscopist was not able to cannulate the common bile duct due to marked edema. Endoscopic ultrasound of the common duct was performed on day #3 and no stones were seen in the
common bile duct. The patient underwent robotic cholecystectomy with indocyanine green (ICG) cholangiogram on
day #4. The patient's post-surgical course was uncomplicated, and he was able to be discharged from the hospital on day #5. The health plan denial letter notes that there was no hemodynamic, pulmonary, neurological, or metabolic reason for acute level of care and that the treatment provided could have been rendered with an observation level of care. This letter
references MCG (Milliman Care Guidelines) Gallbladder or Bile Duct Inflammation or Stone, 26th edition. The denial is being appealed.

The inpatient admission was medically necessary and consistent with the standard of care.

The patient initially presented to the hospital and was admitted with abdominal pain and biochemical findings of biliary obstruction. He was appropriately and promptly managed with nothing by mouth (NPO) status, pain management, and antiemetics. He was promptly imaged with ultrasound that did confirm gallstones and biliary ductal dilatation. Due to the diagnosis of choledocholithiasis, the gastroenterology service was consulted, and the patient underwent further evaluation with magnetic resonance cholangiopancreatogram (MRCP), endoscopic retrograde cholangiopancreatography (ERCP), and endoscopic ultrasound. He underwent laparoscopic (robotic) cholecystectomy with indocyanine green (ICG) cholangiogram on day #4. He did demonstrate clinical improvement on day #5 such that he was suitable for discharge from the hospital. The diagnosis of choledocholithiasis in addition to symptomatic cholecystitis does carry the potential for rapid clinical deterioration. In this case, the care provided required the
coordinated care of multiple medical services (surgery and gastroenterology), required imaging and follow-up labs, clinical assessment over a period of longer than 48 hours, endoscopic retrograde cholangiopancreatography, endoscopic ultrasound, and cholecystectomy. In this case, there was evidence of common bile duct disease with bilirubin over 2 and aspartate aminotransferase/alanine aminotransferase (AST/ALT) markedly elevated. Inpatient care was medically necessary in this case based on standard of care treatment guidelines.