Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute Cholecystitis

Treatment: full hospital admission

The insurer denied coverage for full hospital admission

The denial is overturned.

This patient has a history of hypertension, hyperlipidemia, diabetes, obstructive sleep apnea, and obesity and presented to the Emergency Department (ED) via ambulance for complaints of weakness, sweating, fever, nausea, vomiting and abdominal pain. Results of an abdominal and pelvic computerized tomography (CT) scan indicated he had gallstones with fluid in his gallbladder along with diverticulosis in his colon. Blood work noted an elevated white blood cell count, liver function tests (LFTs) and bilirubin levels. The patient was admitted to a surgical floor where intravenous antibiotics, pain medication were initiated.  The patient went to the operating room for a laparoscopic cholecystectomy, liver wedge biopsy and repair of an umbilical hernia.

Acute cholecystitis and biliary complaints are a common inpatient diagnosis. Acute cholecystitis is also estimated to attribute to millions of ambulatory visits each year, and is a leading cause of hospital admissions. [1] Studies have shown that ambulatory laparoscopic cholecystectomy is safe and avoids an overnight hospital stay. [2, 4, 5] Factors that contribute to admission after laparoscopic cholecystectomy include drain placement, conversion to open surgery, persistent abdominal pain, nausea, and vomiting. [3] In patients without abnormalities of the bile duct or abnormal liver function tests, ambulatory laparoscopic cholecystectomy is safe and feasible. [5] Ambulatory and/or outpatient laparoscopic cholecystectomies reduce hospital costs without compromising patient outcomes. [6]

Per clinical documentation, this patient presented to the ED with abdominal distention and vomiting. Vital signs in the ED revealed a blood pressure of 170/105 and a heart rate of 170. An electrocardiogram (EKG) gave a heart rate of 107, sinus tachycardia. A computed tomography (CT) scan had findings concerning for acute cholecystitis (cholelithiasis, pericholecystic fluid), diverticulosis, and splenomegaly. The total bilirubin was elevated at 5.9 and the patient was noted to have jaundice. Alkaline phosphatase, alanine transaminase, and aspartate aminotransferase were all elevated at 320, 270, and 173, respectively. White blood cell count was elevated to 14.8. A magnetic resonance cholagiopancreatography (MRCP) was performed due to the elevated liver function tests and did not demonstrate choledocholithiasis. A hepatobiliary iminodiacetic acid (HIDA) scan demonstrated non-visualization of the gallbladder, consistent with cystic duct obstruction and acute cholecystitis. The patient was taken to the operating room and underwent a laparoscopic cholecystectomy, liver biopsy, umbilical hernia repair, and cholangiogram. There were no filling defects noted during the cholangiogram. There were no reported complications postoperatively. LFTs remained elevated postoperatively. The patient began to improve slowly. The patient was discharged. Per Milliman Care Guidelines (MCG) criteria, admission is indicated when there is acute cholangitis as indicated by elevated white blood cell count and total serum bilirubin greater than 2. [7] Peer-reviewed literature and MCG criteria indicate that inpatient admission is necessary in these circumstances. Per provided clinical documentation, inpatient admission was medically necessary. 

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

Based on the above, the medical necessity for the full hospital admission is substantiated. The insurer's denial is overturned.