Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cholecystitis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned
 
This is the case of an adult who presented to the emergency department (ED) with complaint of abdominal pain. The ED provider note indicated the patient complained of 10 out of 10 bloating pain since last night with 2 episodes of vomiting. He denied fever or chills. He was afebrile with tenderness to palpation in the right upper quadrant (RUQ) and epigastrium. White blood cell count (WBC) at was 16.4 with bilirubin of 0.8, aspartate aminotransferase (AST) 15, alanine transaminase (ALT) 23 and alkaline phosphatase of 103. He was taken to ultrasound with findings of dilated common bile duct (CBD) to 1.1 centimeters (cm) with mild intrahepatic biliary dilation with possibility of choledocholithiasis raised. Further assessment with Magnetic resonance cholangiopancreatography (MRCP) was recommended.

Surgery notes indicated abdominal pain, with nausea and vomiting. The patient stated he has had abdominal pain like this in the past. This time it was worse. He had significant pain in the RUQ when they were doing his ultrasound. The provider noted he denied fever. His abdomen was soft, non-distended, mildly tender in lower abdomen, Right greater than Left, with significant tenderness to RUQ without rebound or guarding. Sonogram results noted dilated CBD to 1.1 cm with mild intrahepatic dilation and the possibility of choledocholithiasis rose.

Gastroenterology (GI) was consulted and saw the patient and noted that the abdominal sonogram was suggestive of CBD dilation. Labs included WBC 12.8, bilirubin total 0.5, AST 13, ALT 13, Alkaline phosphatase 126. The provider noted that MRCP was without evidence of CBD stone or intrahepatic dilation- but was suggestive of acute cholecystitis. The patient was given nothing by mouth (NPO) and given intravenous (IV) fluids and IV antibiotics.

MRCP revealed no CBD stones or intrahepatic dilation. These findings were highly concerning for acute cholecystitis with pericholecystic fluid and probable stone impacted in the gallbladder neck.

GI saw the patient and noted mild RUQ pain with MRCP negative for CBD stones. The plan was laparoscopic cholecystectomy today.  Total bilirubin was 1.6 and direct was 0.6 with normal AST, ALT, and Alkaline phosphatase.

Surgery saw the patient and noted the plan for laparoscopic cholecystectomy.

The patient was taken to the operating room and underwent an uneventful lap cholecystectomy. Findings included inflamed gallbladder and unable to pass catheter into the bile duct to perform intraoperative cholangiography (IOC) as the cystic duct was small. Pathology revealed acute necrotizing and hemorrhagic cholecystitis superimposed on chronic cholecystitis with cholelithiasis. The patient did well and was discharged.

This patient did need to be admitted in this case as he could not have been managed on an outpatient/observation basis. He presented to the hospital and had a sonogram which noted CBD to be 1.1 cm. He was taken to the operating room after the MRCP showed no stone in the CBD (it may have passed) and then discharged.  The patient could not have been cared for with an ambulatory observation setting due to the concern for choledocholithiasis. 

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the full hospital admission is substantiated.