Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute Cholecystitis

Treatment: inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.

The denial is upheld.

This is the case of a female patient with past medical history of type 2 diabetes mellitus (DM), asthma who presented to the emergency department (ED) with right upper quadrant (RUQ) pain. The patient presented to the ED complaining of abdominal pain. The patient was afebrile complaining of RUQ and left upper quadrant (LUQ) pain for the past week and a half. The patient denied fever or chills. As per the ED provider note the patient complained of RUQ pain. The patient denied any prior gastrointestinal (GI) issues. The patient had been eating fried fatty foods and recently was diagnosed with DM. On exam the abdomen was soft with RUQ tenderness with a positive Murphy's sign. General surgical consult was ordered. The ED provider notes indicated that the patient was resting comfortably with no pain or acute distress noted at this time. Labs included white blood cell of 7.1 with alkaline phosphatase of 88, aspartate aminotransferase (AST) of 40, alanine aminotransferase (ALT) of 51 and total bilirubin of 1.5. Abdominal sonogram revealed enlarged liver with gallbladder wall thickening with intraluminal sludge and trace pericholecystic fluid. The assessment and plan were acute cholecystitis with the plan to send to the operating room (OR) for lap cholecystectomy. The patient was treated with nothing by mouth (NPO), pain management and antibiotics. The patient was taken to the OR for lap cholecystectomy. The operative note indicated thick-walled gall bladder and intraluminal gallstones. The pathology revealed acute and chronic cholecystitis.

Progress note indicated the patient was afebrile with the abdomen soft and no guarding. The patient denied nausea/vomiting. The plan was to discharge the patient with outpatient follow up.

This patient did not have signs and symptoms for acute cholecystitis as she did not have an elevated white blood cell count (WBC), elevated liver function test (LFT's) or confirmation test for acute cholecystitis. The only test that was done was an ultrasound which showed gallbladder sludge with some mild wall thickening. She also did not have acute cholangitis or common bile duct stone. She did have right upper quadrant tenderness with positive Murphy's sign but did not have other signs of acute cholecystitis and the pain was also present for more than a week. MCG Inpatient and Surgical Care 25th Edition cholecystectomy by laparoscopy also notes that the operative status criteria is ambulatory. Thus, this patient did not require an inpatient admission for this procedure and could have been cared for in an observation/ambulatory setting based upon the Milliman Care Guidelines (MCG) guidelines.

Based upon the records, the inpatient hospital admission was not justified as this patient could have been managed in an ambulatory/observation setting as she did not have markedly elevated and abnormal liver function tests or elevated WBC. She did not meet criteria for an acute admission for acute cholecystitis and she should have been managed in an observation/ambulatory setting as noted by the insurer. 

Based upon these findings the health care plan did act reasonably and with sound medical judgment. 
The insurer's denial of coverage for the inpatient hospital admission is upheld. Medical necessity is not substantiated.