Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute Cholecystitis

Treatment acute inpatient admission

The insurer denied coverage for acute inpatient admission

The denial is upheld

This is the case of a patient with a past medical history of gastroesophageal (GERD) and hypertension (HTN) who presented to the emergency department (ED) with the complaint of abdominal pain. He was afebrile with stable vital signs. As per the ED provider note, he complained of left flank pain since midnight. He reported no history of similar pain in the past. He had nausea but no vomiting. He denied fevers. He had a recent esophagogastroduodenoscopy (EGD) which showed acute gastritis. On exam, he had a soft abdomen, non-distended, tender to palpation in the epigastrium.  He had a HIDA (hepatobiliary iminodiacetic acid) scan which was positive by report for acute cholecystitis. Surgery was called to see the patient. He also had a computed tomography (CT) of the abdomen. He was made aware of renal cyst and instructed for this to have follow up with urology. As per the history and physical he presented with nausea and abdominal pain. His labs showed a white blood count (WBC) of 9.10 liver function test (AST [aspartate aminotransferase] 27, ALT [Alanine transaminase]24), Alkaline Phosphatase 59 and bilirubin total of 1. He was made NPO [nothing by mouth] and plan for OR [operating room] tomorrow for laparoscopic (lap) cholecystectomy.

There was no indication in the chart for the delay in surgery as the HIDA scan was positive, and the patient underwent an MRCP (Magnetic resonance cholangiopancreatography) despite having normal liver function tests. He subsequently had the lap cholecystectomy. This could have been done sooner and in an observation, status as noted by the insurer with the patient discharged within 48 hours of presentation if not sooner. 

According to the guidelines of Milliman Care Guidelines (MCG) Health Inpatient and Surgical Care- 26th edition Gall bladder or bile duct inflammation or stone, 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 mg/L (milligrams per liter), ...  Evidence of common bile duct disease indicated by 1 or more of the following: Total serum bilirubin level greater than or equal to 2 mg/dL (milligrams per deciliter) (34 micromoles/L (liter)), Liver function test (alkaline phosphatase (ALP), r-glutamyl transferase (GGT), AST or 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; ...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. 

This patient did not need to be admitted as he could have been managed with an outpatient or ambulatory basis. He did not have any indication for acute inpatient admission given that he was afebrile, and the labs were normal with normal liver function tests, and normal bilirubin. His HIDA scan was positive for acute cholecystitis, but he did not need to be kept having an MRCP and could have had a lap cholecystectomy and sent home the same day. 

The admission was not justified at the inpatient admission level as the patient should have been managed in an observation setting.  The health care plan did act reasonably and with sound medical judgment. 

The insurer's denial of coverage for acute inpatient admission is upheld. Medical Necessity is not substantiated.