Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute cholecystitis

Treatment: Inpatient admission 

The insurer denied coverage for an inpatient admission 
The denial is upheld

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. [9] Ambulatory and/or outpatient laparoscopic cholecystectomies reduce hospital costs without compromising patient outcomes. [6]

Per clinical documentation, this patient presented to the emergency department with a one-day history of right upper quadrant abdominal pain, chest pain, nausea, and vomiting. Vital signs in the ED (emergency department) were significant for a blood pressure of 174/93 mmHg (millimeters of mercury), pulse of 72, and temperature of 99.3 F (Fahrenheit). An ultrasound demonstrated a distended gallbladder and findings equivocal for acute cholecystitis. The white blood cell count was slightly elevated at 12.5. Liver function tests were within normal limits. The patient was also noted to have chest pain. An ECG (electrocardiogram) demonstrated new findings concerning for ischemia. Cardiology was consulted. An echocardiogram was performed and was normal. The patient underwent a laparoscopic cholecystectomy. A JP (Jackson-Pratt) drain was placed and removed the following day. There were no reported complications. The patient was discharged. Per MCG (Milliman Care Guidelines) criteria, an inpatient admission for acute cholecystitis is indicated for patients with all the following: right upper quadrant pain, a mass, or tenderness; systemic signs of inflammation; or that a cholecystectomy is not anticipated during the current hospital stay. The patient did not have any systemic signs of inflammation and an ultrasound was equivocal for acute cholecystitis. Surgery was planned during the current admission. MCG criteria indicate that inpatient admission was not necessary in this patient. MCG criteria indicates that observation care for chest pain is indicated in those patients with suspected myocardial ischemia as indicated by an ECG consistent with new changes. [10] The patient does meet observation criteria for chest pain. Per provided clinical documentation, inpatient admission was not medically necessary for acute cholecystitis. An observation stay would be more appropriate for chest pain.

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

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