Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute and chronic cholecystitis with focal hemorrhage and necrosis.
Treatment: Inpatient hospital admission.
The insurer denied coverage for inpatient hospital admission.
The denial is overturned.

This is the case of an adult with a history of hypertension (HTN) and cesarean section (C section) who presented to the emergency department (ED) with complaints of right upper quadrant abdominal pain for 3 days. As per the triage note the patient was afebrile with stable vital signs complaining of chest/epigastric pain that radiated to her back. The patient had a prior C section. As per the ED provider note the patient is roughly 30 days post-partum with constant epigastric pain radiating to the back with episodes of non-bloody, bilious emesis. There was no fever or chills. On exam the abdomen was soft non distended, with tenderness in the right upper quadrant (RUQ), epigastric region. Labs included amylase of 36, lipase 20, alkaline phosphatase (ALP) 103, aspartate aminotransferase (AST) 35, alanine transaminase (ALT) 64 and total bilirubin of 0.3. The white blood cell (WBC) count was 11.2. Ultrasound of the right upper quadrant showed mildly distended gallbladder with apparent mobile layering gallbladder sludge. No evidence of wall thickening was noted. 

General surgery was consulted and the patient was to be kept nothing by mouth (NPO). 

Progress notes indicated the patient had no acute events overnight. The patient was NPO in anticipation of surgery. The patient was passing flatus and had adequate pain control. On exam the patient had tenderness to palpation in the RUQ. The plan was to continue antibiotics and NPO for Operating Room today. WBC was 12.4. A hepatobiliary iminodiacetic acid (HIDA) scan indicated cystic duct obstruction and findings compatible with acute cholecystitis.

The patient was taken to the operating room for a laparoscopic cholecystectomy. The pathology revealed acute and chronic cholecystitis with focal hemorrhage and necrosis.

Progress notes indicated the patient felt well and was afebrile and denied vomiting or nausea. There was minimal tenderness on abdominal exam. Liver function tests (LFT's) were noted to be up trending. 

Magnetic resonance cholangiopancreatography (MRCP) was done. Gastroenterology (GI) was called in consultation because of continued significant elevation of liver enzymes post operatively. The plan was to await the MRCP and if LFT's continue to rise then endoscopic retrograde cholangiopancreatography (ERCP) with decompression may be necessary.

GI saw the patient and noted the MRCP showed no evidence of choledocholithiasis. The patient had no abdominal pain or fever or chills. The patient was discharged home. 

Based upon the records the acute inpatient admission was justified as this patient had acute cholecystitis and post op had significant elevation of the liver enzymes which necessitated continued inpatient care. This could not have been managed as noted by the insurer in an ambulatory/observation setting. She did have a positive HIDA scan for acute cholecystitis. 

The patient met criteria according to the Milliman Care Guidelines (MCG) Health Inpatient and Surgical Care- 26th edition Gall bladder or bile duct inflammation or stone ORG: M-555 (ISC). This patient did need admission as they could not have been managed with outpatient/observation basis. 

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.  

The insurer's denial of coverage for inpatient hospital admission is overturned. Medical Necessity is substantiated.