Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cholecystitis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission 

The denial is upheld 

This is the case of a patient who presented for elective admission. As per the history and physical the patient presented planned cholecystectomy. The patient stated they were having abdominal pain for a couple of years but within the last week they experienced severe pain in the right upper quadrant (RUQ) of the abdomen after eating. Abdominal sonogram showed cholelithiasis with abnormal gallbladder distension. The patient denied nausea, vomiting or fever. Exam revealed the patient is obese with abdominal tenderness without guarding or rebound without Murphy sign.

As per the pre-op note, the patient has cholelithiasis with acute-on-chronic calculous cholecystitis. The patient did have a computed tomography (CT) which showed gallstones and suspected gallbladder wall thickening and recommendation for hepatobiliary iminodiacetic acid (HIDA) scan to exclude acute cholecystitis.

The patient underwent laparoscopic cholecystectomy with placement of Jackson-Pratt (JP) drain. Estimated blood loss (EBL) was 20 milliliters (mL). Findings at the time of surgery included that the gallbladder was chronically scarred and contained large amount of small stones. 

Progress notes indicated the patient underwent the procedure which was unremarkable, and the patient was being admitted overnight for observation, pain management with plan for possible discharge home in the morning.

Based upon the records, the acute inpatient admission was not justified as this patient could have been managed in an ambulatory/observation setting after having an uneventful elective laparoscopic cholecystectomy. Since the patient was totally asymptomatic, the patient could have been observed and sent home sooner. In fact, the attending noted that the patient was kept overnight after the surgery for observation. The operation was a scheduled elective operation. Therefore, there was no indication to keep the patient in an inpatient mode but rather observation.  
 
According to the guidelines of MCG Health Inpatient and Surgical Care- 27th 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. This patient did not need to be admitted and could have been managed with an outpatient/observation basis. The patient did not have any indication for acute inpatient admission as this was an elective laparoscopic cholecystectomy. A JP drain was not a reason to keep the patient overnight. There was no indication continued inpatient care rather than just observation. Furthermore, according to MCG Inpatient and Surgical Care 27th Edition cholecystectomy by laparoscopy the operative status criteria is ambulatory. Thus, this patient should have been managed without an inpatient acute admission for this procedure. 

Furthermore, using the criteria that the hospital used -  MCG Health in General recovery care 27th edition General admission criteria GRG: CG-GAC (ISC GRG), the guidelines note that admission is indicated for 1 or more of the following: Hemodynamic instability; Acute cardiac or peripheral ischemia; Cardiac arrhythmias of immediate concern;  Severe respiratory findings; etc.  Based upon these guidelines, this patient did not need an acute admission but rather should have been observed after having an elective laparoscopic cholecystectomy. 

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 an inpatient admission is not substantiated.