Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute Cholecystitis. 
Treatment: Inpatient Hospital Stay. 

The insurer denied the Inpatient Hospital Stay. 
The determination is overturned. 

This is a male patient who presented to the emergency department (ED) with abdominal pain of 3-days duration. His past medical history included hypertension. At the time of presentation, the patient was without a fever, the heart rate was 98 and blood pressure was 169/97 millimeters of mercury (mmHg). He was tender in the right upper abdomen. The white blood cell count (WBC) count was elevated at 16 thousand (K). The complete metabolic panel identified normal serum transaminases and slightly elevated bilirubin (1.3). An abdominal ultrasound and computed tomography (CT) scan showed gallstones and findings of acute cholecystitis. He was admitted to the hospital with the diagnoses of acute cholecystitis. He was started on intravenous (IV) antibiotics. A laparoscopic cholecystectomy was planned. 

The next day, the patient had an elevated temperature up to 102.1 degrees Fahrenheit (F). The heart rate was elevated at 101 beats/minute. The white blood cell count (WBC) count was further elevated at 18 K. The surgical team recommended a cholecystectomy. However, the patient declined this intervention and opted to leave the hospital against medical advice. He was provided a prescription for oral antibiotics at the time of his leaving the hospital. 

An inpatient level of care was medically necessary in this case. This patient presented to the hospital with acute cholelithiasis/cholecystitis, a markedly elevated WBC count, and fever. He was appropriately admitted to the hospital with the diagnoses of acute cholecystitis. He had a markedly elevated WBC count and had confirmation of the acute cholecystitis based on imaging with an ultrasound and CT scan. He required intravenous (IV) antibiotics and acute surgical intervention was planned. It was reasonably anticipated that the necessary care would span a period of more than 48-hours. The WBC count was further elevated and he had a fever overnight up to 102.1 degrees Fahrenheit (F). A laparoscopic cholecystectomy was advised. However, the patient declined the recommended treatment and left the hospital against medical advice. 
 
Inpatient care is appropriate when there is right upper quadrant pain, and systemic signs of inflammation (fever, C-reactive protein greater than (>) 10, WBC count > 10 K). Inpatient admission may also be indicated for acute cholangitis, common bile duct obstruction, vomiting that is severe or persistent, dehydration that is severe or persistent, hemodynamic instability, severe pain requiring acute inpatient management, signs of intestinal obstruction, bacteremia, need for percutaneous or open procedures, or other condition that requires inpatient admission. The documentation in this case does support that these criteria (fever and leukocytosis with imaging confirmation of acute cholecystitis) were satisfied to justify an inpatient level of care. That the patient left the hospital against medical advice does not detract from the intensity of service and level of care provided. The clinical conditions support the need for an inpatient level of care per the Milliman Care Guidelines (MCG) (4).