Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cholecystitis. 
Treatment: Inpatient admission. 
The insurer denied coverage for inpatient admission. 
The denial is upheld. 
 
This is the case of an adult who presented to the emergency department (ED). As per the triage note the patient presented with epigastric pain. His vital signs were stable, and he was afebrile. He denied shortness of breath (SOB) and radiation of pain. As per the ED provider note the patient presented to the ED complaining of pain 8/10 radiating to the left chest. He noted his wife is home with COVID. He denied fever, chills, abdominal pain, SOB, nausea or vomiting. On exam he had bowel sounds in all 4 quadrants and epigastric tenderness to palpation, with a non-distended abdomen. There was no rebound or guarding. The plan was labs, computed tomography (CT) of the abdomen.  His amylase was 50 (normal), white blood cells (WBC) 9.3, D dimer < (less than) 0.27 (normal), chest x-ray within normal limits, abdominal X ray with nonspecific bowel gas pattern.  Liver function tests were normal. The assessment was cholecystitis. The plan was intravenous (IV) antibiotics. 

The patient was taken to the operating room. The patient underwent an uneventful laparoscopic cholecystectomy. Progress notes indicated the patient had no acute events overnight. The patient was afebrile with stable vital signs and pain was well controlled. Hospitalist medicine also saw the patient and noted the patient was doing well without exhibiting signs of COVID (coronavirus disease) with oxygenation at 95% (percent).
	
According to the Milliman Care Guidelines (MCG) Health Inpatient and Surgical Care- 27th edition Gall bladder or bile duct inflammation or stone ORG: M-555 (ISC) 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 as indicated by ALL of the following: Systemic signs of inflammation indicated by 1 or more of the following: Fever, C-reactive protein level greater than 10, White blood cell count greater than 10 or less than 4;  Evidence of common bile duct disease indicated by 1 or more of the following: Total serum bilirubin level greater than or equal to 2, Liver function test (alkaline phosphatase (ALP), r-glutamyl transferase (GGT), aspartate aminotransferase (AST), or alanine aminotransferase (ALT)) greater than 1.5 times the upper limit of normal, Hepatobiliary imaging showing biliary dilatation or evidence of etiology (e.g., stricture, stone, previously placed stent); 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, White blood cell count greater than 10 or less than 4 and Cholecystectomy not anticipated (i.e., not during current hospital stay) due to 1 or more of the following: High surgical risk (e.g., severe comorbidities, organ failure), Interval cholecystectomy planned (i.e., not during current hospitalization); Calculus or obstruction of gallbladder or bile duct and 1 or more of the following: Hemodynamic instability, Common bile duct obstruction diagnosed (e.g., by imaging), Vomiting that is severe or persistent, Dehydration that is severe or persistent,  Severe pain requiring acute inpatient management, Bacteremia. 

Based on the above, the insurer's denial must be upheld. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for full hospital admission is not substantiated.