Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic Cholecystitis with biliary colic

Treatment inpatient level of care

The insurer denied coverage for inpatient level of care

The denial is upheld

This patient with past medical history of hypertension, hyperlipidemia (HDL), anxiety, depression presented to the emergency department (ED) with right upper quadrant (RUQ) abdominal pain and nausea. He was afebrile with stable vital signs. He was seen by his Gastroenterologist doctor who sent him to the ED for possible cholecystitis. His abdomen was soft, tender in the RUQ. He was NPO [nothing by mouth/no oral intake]. The nurse inquired about his NPO status as he might not go to the operating room (OR) until the next morning. 

He denied, fever, chills, nausea or voting. Exam revealed the abdomen to be soft, non-distended with no rebound but with RUQ tenderness. White blood count (WBC) was 7.67. Sonogram revealed gall bladder sludge with trace pericholecystic fluid and positive Murphy' sign. No gallbladder wall thickening was noted. The radiologist noted that if there was clinical concern for acute cholecystitis a hepatobiliary iminodiacetic acid (HIDA) scan may be obtained. Surgery noted no HIDA scan at this time and the plan was NPO, cardiology consultation for preop risk stratification, and COVID testing.

He was cleared by Cardiology and by medicine for surgery.

Surgery progress note indicated, "the patient was admitted yesterday and his pain improved since beginning antibiotics. He denied abdominal pain, nausea or vomiting. He was afebrile with stable vital signs. The plan was OR (operating room) today." Of note the consent for surgery was signed.

The patient underwent an uneventful laparoscopic (lap) cholecystectomy. Post-operative check revealed the patient was stable, out of bed (OOB) with pain controlled.

Progress note indicated the patient was doing well and he was discharged for outpatient follow up.

Based upon the records provided the inpatient level of care was not justified as this patient did not have acute cholecystitis but more likely chronic cholecystitis with biliary colic as he did not have markedly elevated and abnormal liver function tests (LFT)or elevated WBC. He could have been managed in an observation/ambulatory setting.

According to Milliman Care Guidelines (MCG) Health Inpatient and Surgical care - 25th edition Gall bladder or bile duct inflammation or stone 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. 

This patient did not have signs and symptoms for acute cholecystitis as he did not have an elevated WBC, elevated LFT's or confirmation test for acute cholecystitis. In fact, the radiologist noted that a HIDA scan would have been warranted to confirm acute cholecystitis, but it was not done. The only test that was done was an ultrasound which showed gallbladder sludge without wall thickening. He also did not have acute cholangitis or common bile duct stone. He did have right upper quadrant tenderness with positive Murphy's sign but did not have gallbladder wall thickening or markedly elevated liver enzymes or WBC. MCG Inpatient and Surgical Care 25th Edition cholecystectomy by laparoscopy notes that the operative status criteria is ambulatory. This patient did not require an inpatient admission for this procedure and could have been cared for in an observation/ambulatory setting based upon the MCG guidelines.

The inpatient level of care was not justified at the inpatient admission level as the patient did not have acute cholecystitis/cholangitis and could have been managed in an observation setting. The health care plan did act reasonably and with sound medical judgment.   

The insurer's denial of coverage for inpatient level of care is upheld. Medical Necessity is not substantiated.