Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic cholecystitis

Treatment: Inpatient admission  

The insurer denied coverage for inpatient admission. The denial was upheld.

This patient is a male who presented to the hospital for a cholecystectomy due to chronic cholecystitis. As per the Ambulatory Surgical Unit (ASU) note the patient had clears the night before. His vital signs were stable, and he was afebrile. He arrived at ASU for an apparent elective laparoscopic (lap) cholecystectomy. The patient underwent an uneventful lap cholecystectomy and without complication. The surgical pathology report revealed cholelithiasis and chronic cholecystitis. As per the ambulatory surgery center discharge instruction, the patient was to be discharged. 

Based upon the records submitted, the medical necessity of inpatient admission was not justified at an acute level of care as this patient could have been treated on a 23 hour observation status. The patient underwent elective lap cholecystectomy with operative time of 80 minutes. The operative note indicated an uneventful lap cholecystectomy. His vital signs were completely stable post op and he was tolerating liquid diet with pain controlled.

According to MCG Health Inpatient and Surgical care- 23rd edition Gall bladder or bile duct inflammation or stone ORG: M-555 (ISC) clinical indications for admission to inpatient care may include patients with 1 or more of the following: Acute cholecystitis as indicated by ALL of the following: Right upper quadrant pain, mass, or tenderness; Systemic signs of inflammation indicated by 1 or more of the following: Fever, C-reactive protein level greater than 10 mg/L, White blood cell count greater than 10,000/mm3 (10 x109/L) or less than 4000/mm3 (4 x109/L), etc. Furthermore, according to MCG health Inpatient and surgical care 23rd edition Cholecystectomy by Laparoscopy ORG: S-365 (ISC), the length of stay goal is ambulatory. Extended Stay as defined by Minimal (a few hours to 1 day), Brief (1 to 3 days), Moderate (4 to 7 days), and Prolonged (more than 7 days) can be seen. Finally, according to MCG Guidelines General Recovery Care 23rd Edition Ambulatory Surgery or procedure GRG: PG-AS (ISC GRG) potentially ambulatory surgery or procedure covered by this guideline (i.e., not covered more specifically by another guideline) may proceed on an ambulatory basis as indicated by ALL of the following: No inpatient care needed for preoperative disease or condition; Not emergent procedure; No complex surgical approach or situation anticipated; Low risk procedure or patient not at high anesthetic risk; No drug-related risk; No inadequate outpatient care situation.

This patient did not need acute care services or continued care as he met criteria for these guidelines as this was an ambulatory procedure as the procedure could have been readily done in an ambulatory setting. He did not have any complication that required inpatient stay. Observation for 23 hours is included when performing this procedure. 

The health plan did act reasonably and with sound medical judgment and in the best interest of this patient. 

Based on the above, the medical necessity for the inpatient admission is not substantiated. The insurer's denial is upheld.