Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cholelithiasis and cholecystitis
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.


The patient presented to the hospital emergency department (ED) with right upper abdominal pain and nausea. She had a past medical history of asthma. She had tenderness in the right upper abdomen. At the time of presentation, the patient was without a fever and her vital signs were normal. The white blood cell (WBC) count was normal at 7.7 thousand (K). The complete metabolic panel identified elevated transaminases and bilirubin. An ultrasound showed gallstones and biliary ductal dilatation. Magnetic resonance cholangiopancreatography (MRCP) was subsequently performed confirming the diagnosis of cholelithiasis.
She was initially treated with intravenous (IV) fluid and IV antibiotics. The patient underwent an endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy. Two stones were swept from the common bile duct (CBD). She underwent a laparoscopic cholecystectomy. The operative dictation describes an uncomplicated cholecystectomy procedure. She was started on a clear liquid diet. The patient was considered to be stable for discharge home with arrangements for outpatient follow up.
At issue is the medical necessity of an inpatient stay.
An inpatient level of care was medically necessary.
This patient presented to the hospital with cholelithiasis and cholecystitis. Imaging with an ultrasound, in addition to lab data support this diagnosis. Additionally, the patient did have biochemical jaundice with elevated bilirubin and imaging confirmation of CBD stones with biliary ductal dilatation and CBD stones identified on endoscopic ultrasound and ERCP. Two stones were extracted from the CBD at the time of EERCP with sphincterotomy. The patient underwent a cholecystectomy procedure. Her post-surgical course was uncomplicated. Diet was advanced. Vital signs remained normal.
An inpatient stay was consistent with the Milliman Care Guidelines (MCG) during this time. MCG Gallbladder or Bile Duct Inflammation 24th edition. state that the goal length of stay is ambulatory but that inpatient care is needed when there is:
Failure to achieve discharge status criteria, Conversion to open surgery, Severe systemic infection, Care for active comorbidities,	Calculus or obstruction of gallbladder or bile duct and one or more of the following: hemodynamic instability, CBD obstruction diagnosed by imaging, vomiting that is severe, dehydration that is severe or persistent, severe pain, bacteremia, or Complications of the procedure.

In this case, the submitted documentation does support that these clinical conditions (Calculus or obstruction of gallbladder or bile duct and CBD obstruction diagnosed by imaging) existed to warrant an inpatient level of care.
This patient was treated in an expeditious and efficient manner and although her care was provided over less than two days, the intensity of service, the coordination of multiple medical services (gastroenterology [GI] and surgery), the diagnosis of choledocholithiasis in addition to cholelithiasis/cholecystitis, and the submitted MCG noted above support the medical necessity of an inpatient designation in this case.