Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute Cholecystitis

Treatment: Inpatient emergency admission

The insurer denied coverage for inpatient emergency admission.

The denial is upheld.

This is the case of a patient with no significant past medical history who presented to the emergency department (ED) with complaints of right upper quadrant (RUQ) abdominal pain. As per the ED provider note, the patient presented with epigastric abdominal pain since that morning. The pain radiated to the periumbilical area. The patient denied nausea or vomiting. The vital signs were stable. The abdomen was soft with distension and abdominal tenderness. There was no guarding with periumbilical and epigastric abdominal tenderness and equivocal Murphy sign. The blood count revealed no leukocytosis. Computed tomography (CT) suggested possible cholecystitis and the patient was evaluated by surgery who recommended admission to the medical service for further evaluation. CT scan done showed mild gallbladder wall thickening with pericholecystic fat stranding. These findings are suspicious for acute cholecystitis but are somewhat confounded by labs indicating no clinical significance. They recommended hepatobiliary iminodiacetic acid (HIDA) scan. Empiric intravenous (IV) antibiotics were started.

HIDA scan was done which showed no evidence of cystic duct obstruction; acute cholecystitis would be highly unlikely. There was no evidence of CBD [common bile duct] obstruction. Progress note indicated if cholecystitis ruled out consider EGD [esophagogastroduodenoscopy]. Surgery saw the patient and noted no acute surgical intervention needed at this time; advance diet as tolerated.

Based upon the records, the emergency hospital admission was not justified as this patient could have been managed in an ambulatory/observation setting as he did not have elevated white blood cells (WBC), fever, or abnormal liver function test (LFT's) or a confirmatory test to show that he had acute cholecystitis. In fact, the surgical consult noted low suspicion for acute cholecystitis. He did not meet criteria for an acute admission for acute cholecystitis, so he could have been managed in an observation/ambulatory setting as noted by the insurer. 

According to the 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. The clinical indications for admission to inpatient care may include patients with 1 or more of the following: acute cholangitis as indicated by ALL of the following: systemic signs of inflammation indicated by 1 or more of the following: fever, C-reactive protein level greater than 10 mg/L [milligrams per liter], white blood cell count... interval cholecystectomy planned (i.e., not during current hospitalization); calculus or obstruction of gallbladder or bile duct and 1 or more of the following: hemodynamic instability, common bile duct obstruction diagnosed (e.g., by imaging), vomiting that is severe or persistent, dehydration that is severe or persistent, severe pain requiring acute inpatient management, bacteremia. 

This patient did not have signs and symptoms for acute cholecystitis as he did not have elevated WBC, fever or confirmatory test to show acute cholecystitis. In fact, HIDA scan showed that there was no evidence of acute cholecystitis. Had this been done much sooner, the patient could have been discharged sooner. 

The health plan acted reasonably, with sound medical judgment, and in the best interest of the patient.

Based on the above, the medical necessity for the inpatient admission is not substantiated. The insurer's denial is upheld.