Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Biliary Dyskinesia

Treatment: Inpatient hospital admission 

The insurer denied coverage for the inpatient hospital admission

The denial is upheld

This is a patient with a history of gastroesophageal reflux disease (GERD), hyperlipidemia, coronary artery disease and renal cancer. The patient presented to the Emergency Department (ED) from home with right upper quadrant (RUQ) abdominal pain associated with nausea for 1 week. He was afebrile with stable vital signs. The patient was in no apparent distress. The patient reported that he ate a fatty meal and developed severe acute RUQ pain that radiated across his epigastrium. He had 1 episode of mild emesis with nausea. Exam revealed the abdomen to be soft, non-distended with RUQ tenderness with palpable gallbladder and positive Murphy's sign. Bloodwork was unremarkable however a RUQ abdominal sonogram revealed gallbladder wall thickening and pericholecystic fluid although no discrete gallstones were identified- acute cholecystitis could not be excluded. The patient was admitted for further evaluation, treatment, and monitoring. He was started on antibiotics, intravenous (IV) fluids and ordered to have nothing by mouth (NPO). A hepatobiliary iminodiacetic acid (HIDA) scan with cholecystokinin was performed the following day and was positive for ejection fraction (EF) of 21 percent consistent with biliary dyskinesia.

The patient was medically optimized for surgery and went to the operating room for a laparoscopic (lap) cholecystectomy, umbilical hernia repair and lap peritoneal transversus abdominis plane block. The patient tolerated the procedure well. His diet was slowly advanced, and pain was controlled. The patient was judged medically stable and discharged the following day. 

According to Milliman Care Guidelines (MCG), Health Inpatient and Surgical care- 25th edition Gall bladder or bile duct inflammation or stone (1), 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. He did have right upper quadrant tenderness and had biliary dyskinesia and underwent an uneventful lap cholecystectomy and was discharged the following day - all of which should have been done in an observation/ambulatory setting. Furthermore, according to MCG Inpatient and Surgical Care (2) the operative status criteria is ambulatory. Thus, this patient should have been managed without an inpatient acute admission for this procedure.

Based upon the records, the inpatient hospital admission was not justified as this patient could have been managed in an ambulatory/observation setting as he did not have acute cholecystitis. In fact, he had a HIDA scan which showed biliary dyskinesia and not acute cholecystitis. He did not meet criteria for an acute admission for acute cholecystitis as he could have been managed in an observation/ambulatory setting. 

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

The insurer's denial of coverage for the inpatient hospital admission is upheld. Medical Necessity is not substantiated.