Appeal type: Medical necessity
Decision: Upheld


Diagnosis: Cholecystitis.

Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is upheld.


This is an adult female who presented to the Emergency Department (ED). The ED provider indicated the patient had sudden epigastric and right upper quadrant (RUQ) pain. The patient was obese and had tenderness to palpation in the epigastrium. The case was discussed with surgery who recommended admission to surgery.

The patient had an uneventful laparoscopic cholecystectomy. Post-operatively, the patient was afebrile with stable vital signs. Progress notes, day 1 post-op, indicated the patient was ambulating, passing gas and voiding freely. The patient was tolerating clear liquid diet and denied fever or chills. The patient was doing well.

According to the Milliman Care Guideline (MCG) Health Inpatient and Surgical Care- 26th 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 mg/L(milligrams per liter ), White blood cell count greater than 10,000/mm3(10 x109/L) or less than 4000/mm3 (4 x109/L);  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 (34 micromoles/L), 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 mg/L, White blood cell count greater than 10,000/mm3 (10 x109/L) or less than 4000/mm3 (4 x109/L) 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. 

It should be noted that there was mention of question of seizure however there was no documentation presented to this effect. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for inpatient hospital admission is not substantiated.