Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal/Acute Cholecystitis.
Treatment: Inpatient Hospital Admission.
The health plan denied the requested inpatient hospital admission as not medically necessary. 
The health plan's determination is upheld.

The patient is a woman who presented  with complaints of chest pain of one day duration. Comorbid health conditions included migraines and costochondritis. Vital signs were normal at the time of presentation. The white blood cell count (WBC) count was normal at 7.12 and liver enzymes and bilirubin were normal. The patient was admitted to the hospital and was started on intravenous (IV) antibiotics. The surgical history and physical (H&P) states that she had slight tenderness in the right upper quadrant. A computed tomography (CT) scan and ultrasound showed gallstones in the gallbladder and gallbladder wall thickening.
The progress note states that cholecystectomy was planned. Her pain was improved, but she still had nausea. The patient underwent a laparoscopic cholecystectomy . The operative dictation describes a distended inflamed gallbladder with hydrops. A laparoscopic cholecystectomy was performed without complication.
The next day, the diet was advanced, and pain was controlled with oral medications. Vital signs were normal. The patient remained clinically stable and was discharged from the inpatient setting.
At issue is the medical necessity for the inpatient hospital admission.

The health plan's determination of medical necessity is upheld, in whole.

No. An inpatient level of care was not medically necessary in this case.
This patient was a woman who presented to the hospital with the complaints of chest pain. At the time of presentation, the patient had normal vital signs and normal lab data. An ultrasound and CT scan confirmed cholelithiasis/cholecystitis as the etiology for her complaints. Surgical consultation was requested. The diagnosis and indication for cholecystectomy was established. The patient underwent a laparoscopic cholecystectomy.
There is no documentation of hemodynamic, pulmonary, neurological, or metabolic reason for an acute inpatient level of care at the time of presentation. Additionally, there is no documentation of failure to achieve discharge criteria, conversion to open surgery, care for comorbidities, procedural complications, or any other condition requiring inpatient admission. The perioperative and early post-surgical recovery were uncomplicated, and the patient was stable for discharge from the hospital on the first post-surgical day. Acute inpatient care was not medically necessary for this patient, as the care and treatment provided could have been rendered with a lower level of care.
A lower level of care would have provided for initial assessment, perioperative care and monitoring, provision of intravenous fluid, surgical consultation, performance of a cholecystectomy, and overnight care. There were no peri-procedure complications or other clinical issues.
Inpatient care may be needed when there are metabolic or hematologic abnormalities as measured by liver enzymes and bilirubin and an elevated WBC count. Inpatient care may also be needed in the setting of acute cholecystitis (right upper quadrant pain or tenderness, systemic signs of inflammation). Other criteria for inpatient admission may include:
1) Failure to achieve discharge criteria.
2) Conversion to open surgery.
3) Severe post-operative infection.
4) Care for active comorbidities.
5) Complications of procedure.
6) Gallstone ileus.