Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute cholecystitis.

Treatment: Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission.

The denial is overturned. 

This is a male patient with a past medical history of hypertension (HTN), and a surgical history of open appendectomy, who presented to the Emergency Department (ED) with complaints of one day of abdominal pain and vomiting. The patient's exam of the abdomen revealed normal bowel sounds with tender to palpation over the right upper quadrant (RUQ). His ultrasound in the ED showed 2.2 centimeters (cm) stone in the gallbladder neck with wall thickening and pericholecystic fluid.  Surgical exam revealed positive Murphy sign with guarding and rebound tenderness in the abdomen.  The patient was afebrile. His white blood cell (WBC) count was 8.6 with lipase was 320, and the patient's liver function tests (LFTs) were normal. The plan was nothing-by-mouth (NPO) status, intravenous (IV) fluid, antibiotics, computed tomography (CT) of the abdomen and operating room (OR) the next day for laparoscopic cholecystectomy. CT of the abdomen showed distended gall bladder with gallstones and pericholecystic fluid concerning for cholecystitis.  The patient was admitted with plan for laparoscopic cholecystectomy, IV fluids, IV antibiotics and pain management. The patient underwent an uneventful laparoscopic cholecystectomy with lysis of adhesions and primary repair of ventral hernia.  

Based on the review of the medical record, the inpatient admission was medically necessary for this patient. The patient's care was justified at an acute level of care as this patient did have clinical findings that required an inpatient admission. The patient had RUQ pain with Murphy's sign consistent with acute cholecystitis on sonogram and an elevated lipase consistent with mild pancreatitis. Although this patient did not have a significantly elevated WBC count or a fever, the patient's CT scan and abdominal ultrasound documented findings consistent with acute cholecystitis with a positive Murphy's sign. There was gallbladder wall thickening and pericholecystic fluid. The patient also had an elevated lipase on admission which implied pancreatitis, although he did have normal LFTs.  The admission was therefore, warranted, and the patient could not have had the laparoscopic cholecystectomy done under an observation setting.  

According to the Milliman Care Guidelines (MCG) guidelines on Gall bladder or Bile Duct Inflammation or Stone, the goal length of stay is ambulatory or 2 days and assumes optimal recovery, decision making, and care. 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.  In this case, this patient did have clinical signs and symptoms for acute cholecystitis and confirming imaging on his abdominal ultrasound and CT scan. The patient had a positive Murphy's sign, gallstones as well as pericholecystic fluid and wall thickening. The patient also had an elevated lipase consistent with pancreatitis. The patient therefore, met the MCG guidelines for acute admission. In addition, although MCG Inpatient and Surgical Care 24th Edition cholecystectomy by laparoscopy notes that the operative status criteria is ambulatory, in this case the patient needed to be admitted and cared for in an inpatient setting given his acute cholecystitis associated with purulent gallbladder fluid and need for intravenous antibiotics. Thus, this patient could not have had the cholecystectomy done in an ambulatory /observation care setting, and did meet criteria for inpatient admission.

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

The medical necessity for the inpatient hospital admission is substantiated. The insurer's denial should be overturned.