Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Choledocholithiasis. 

Treatment: Inpatient hospital admission.

The insurer denied coverage for inpatient hospital admission.

The denial is upheld. 

This female patient has a past medical history of anemia and obesity who presented to the Emergency Department (ED) with complaints of burning epigastric pain. The ED attending physician noted the history of epigastric pain, status post gastric bypass, abdominal pain, nausea and vomiting for 3 days. The patient had similar episode 2 months prior but was not evaluated due to COVID-19. Her symptoms at that time resolved without intervention. The patient's abdomen was soft, non-distended with epigastric and right upper quadrant (RUQ) tender to palpation (TTP). The plan was to obtain labs, sonogram, and treat the patient with a gastrointestinal cocktail. The patient's labs included aspartate transaminase (AST) 185, alanine transaminase (ALT) 354, alkaline phosphatase 166, total bilirubin 2.8, lipase 36, and white blood cell (WBC) 7.58. Surgery was consulted and noted the patient was found to have a transaminitis and elevated bilirubin. The patient's RUQ sonogram showed stones and a dilated common bile duct (CBD) to 6 millimeter (mm) with a possible stone in the distal CBD. Surgical exam revealed the patient's abdomen was non-distended with epigastric pain but without rebound or guarding; there was no Murphy's sign. Surgery recommended gastroenterology evaluation and trend liver function tests (LFTs), magnetic resonance cholangiopancreatography (MRCP) and likely plan for cholecystectomy. The patient was admitted and noted to have abnormal LFTs consistent with choledocholithiasis with obstruction. Gastroenterology (GI) evaluation for endoscopic retrograde cholangiopancreatography (ERCP) was recommended. Antibiotics were deferred given no fever or leukocytosis. The GI attending noted that it was possible the CBD stone has passed and to plan for MRCP/ERCP unless surgery is done first and if so, intraoperative cholangiogram (IOC) should be done. Hospital medicine noted that the patient could not get MRCP due to body piercings. The plan was cholecystectomy for cholelithiasis. GI follow-up noted that they would not be doing an ERCP and that the patient has likely passed a stone. The patient underwent laparoscopic cholecystectomy with IOC. Pathology report revealed gall bladder with cholelithiasis. Progress notes revealed the patient was doing well and tolerating diet and was discharged for outpatient follow-up with surgery. 

According to the MCG guidelines for gall bladder or bile duct inflammation or stone (ORG: M-555), 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. The clinical indications for admission to inpatient care may include patients with 1 or more of the following: (1) Acute cholangitis; (2) Acute cholecystitis; (3) Calculus or obstruction of gallbladder or bile duct and 1 or more of the following: Hemodynamic instability, CBD obstruction, Vomiting that is severe or persistent, Dehydration that is severe or persistent, Severe pain requiring acute inpatient management, Bacteremia. 
This patient did not have acute cholecystitis, did not have acute cholangitis and in fact passed a stone with down-trending of her LFT's. She did not have a significantly elevated WBC or ultrasound with findings consistent with acute cholecystitis. The patient had an elevated alkaline phosphatase and elevated transaminitis in the setting of passing a stone. The laparoscopic cholecystectomy with IOC could have been done in observation.

The health plan acted reasonably with sound medical judgment and in the best interest of the patient. 

The medical necessity for inpatient hospital admission is not substantiated. The insurer's denial should be upheld.