Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute Cholecystitis
Treatment: Inpatient Hospital Admission
The insurer denied coverage for the inpatient hospital admission.
The denial is upheld.

The patient is adult male with history of hyperlipidemia and gastric ulcers who presented to the emergency department (ED) with complaints of abdominal pain. As per the emergency department (ED) provider note, the patient reported that since midnight he had acute onset sudden back pain radiating to the epigastric area. He also began to have some nausea and shortness of breath (SOB). He was recently seen in the ED for the same concern. Sonogram then showed gallbladder dilation. Computed tomography (CT) of the abdomen/pelvis showed a hemangioma. He was discharged then with gastroenterology (GI) follow up. He denied fevers, chills, vomiting. Upon presentation he was afebrile with stable vital signs. Exam revealed the abdomen to be soft without distension. There was no abdominal tenderness, and he was negative for Murphy's sign. The plan was labs, computed tomography (CT) angiogram and sonogram. Surgery was consulted for suspected acute cholecystitis. CT angiogram was negative for aneurysm or dissection. The gallbladder was distended with mild wall thickening and pericholecystic fluid and it was noted that if clinical concern persists, they recommended nuclear medicine hepatobiliary iminodiacetic acid (HIDA) scan.

General surgery saw the patient and noted that the patient was febrile to 38.4 degrees Celsius, with labs significant for white blood cells (WBC) of 14, with unremarkable liver function test (LFT's). Computerized tomography angiography (CTA) was negative for aortic dissection. However, imaging revealed possible acute cholecystitis with worsened mild gallbladder distension, wall thickening, and pericholecystic fluid from prior scan. Surgery also noted the abdomen was soft, non-tender, and negative for Murphy's sign. The patient was made nothing by mouth (NPO), intravenous (IV) fluid, Ceftriaxone.  
The patient was taken to the operating room for an uneventful lap cholecystectomy. Pathology revealed acute cholecystitis and cholelithiasis. Postop check indicted the patient was doing well with stable vital signs. Diet was advanced and the patient was discharged.

Based upon the record, the inpatient admission was not justified as this patient should have been managed in an ambulatory/observation setting. 

According to Milliman Care Guidelines (MCG) Inpatient and Surgical Care 26th Edition cholecystectomy by laparoscopy the operative status criteria is ambulatory, and in this case the patient did not require inpatient stay but rather ambulatory status with observation.

MCG General Recovery care 26th edition Ambulatory surgery exception criteria notes that potentially ambulatory procedure or surgery warrants inpatient care due to 1 or more of the following: Inpatient care needed for clinically significant preoperative disease or condition; Complex surgical approach or situation anticipated; Procedure is not low risk and patient at high anesthetic risk; Presence of drug-related risk; Inadequate outpatient care situation; Postoperative event, condition, or finding that warrants inpatient stay. Given the above, the patient did not warrant inpatient status as there was no concern for a clinically significant preoperative disease. 

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 the inpatient hospital admission is not substantiated.