Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute cholecystitis

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.

The denial is upheld.

This patient has a history of gallstones. She presented to the emergency room (ER) with complaints of epigastric pain radiating to the back. The patient was found to have elevated liver function tests (LFT's). The patient was administered intravenous (IV) fluids and was evaluated by Surgery, who recommended admission for further evaluation and surgical management. The patient underwent a laparoscopic cholecystectomy.

Acute cholecystitis and biliary complaints are a common inpatient diagnosis. Acute cholecystitis is also estimated to attribute to millions of ambulatory visits each year and is a leading cause of hospital admissions. [1] Studies have shown that ambulatory laparoscopic cholecystectomy is safe and avoids an overnight hospital stay. [2, 4, 5] Factors that contribute to admission after laparoscopic cholecystectomy include drain placement, conversion to open surgery, persistent abdominal pain, nausea, and vomiting. [3] In patients without abnormalities of the bile duct or abnormal liver function tests (elevated alkaline phosphatase and total bilirubin), ambulatory laparoscopic cholecystectomy is safe and feasible. [5, 8] A 50% increase in the liver function tests can be labelled as mild elevation and is considered negligible by many.

Per clinical documentation, this patient presented to the emergency department with right-sided back pain radiating to the epigastric area. Vital signs in the emergency department (ED) were consistent with hypertension that resolved without treatment. The patient was afebrile. An ultrasound had findings highly suspicious for acute cholecystitis. Liver function tests were normal except for aspartate transaminase that was mildly elevated at 62. Clinical documentation notes that the patient wanted to "defer surgery" at that time. The patient was admitted and started on IV antibiotics. Alkaline phosphatase, aspartate transaminase, and alanine aminotransferase increased the following day to 170, 352, and 457, respectively. The alkaline phosphatase and total bilirubin were not elevated more than 50%. Also, the labs were obtained the morning of/before surgery. There was no need for continued admission after the surgical procedure. Labs were not measured after the procedure either. An MRCP (Magnetic resonance cholangiopancreatography) was performed and there was no indication of choledocholithiasis. The patient underwent a laparoscopic cholecystectomy. There were no reported complications. Liver function tests were not obtained postoperatively. The patient was discharged. Per Milliman Care Guidelines (MCG) criteria, admission is indicated when common bile duct obstruction is indicated via imaging and there are signs of systemic inflammation. [7] Peer-reviewed literature and MCG criteria indicate that inpatient admission is not necessary in this circumstance. Per provided clinical documentation, inpatient admission was not medically necessary. 

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