Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cholecystitis
Treatment: Inpatient hospital admission
The insurer denied coverage for an inpatient hospital admission. 
The denial is upheld.

This is the case of a female with no PMHX (prior medical history) who presented to the ED (emergency department) with complaints of non-radiating, epigastric pain associated with nausea. On exam she had epigastric pain and RUQ (right upper quadrant) tenderness without guarding or rebound. The diagnosis was epigastric pain and cholecystitis. The surgical team saw the patient and recommended admission to surgery. 

Based upon the records, I do feel that the inpatient hospital admission was not justified as this patient could have been managed as noted by the insurer in an ambulatory/observation setting as she had an uneventful laparoscopic cholecystectomy. Furthermore, the patient did not have a fever, or elevated WBC (white blood cell count) or abnormal LFT's (liver function tests) and did not have evidence of cholecystitis on the sonogram but rather had a stone at the neck/infundibulum and probably had biliary colic and not acute cholecystitis. Murphy's sign was negative and the sonogram was without wall thickening or pericholecystic fluid. I therefore believe she did not need an acute inpatient hospital admission as noted by the insurer but rather to be treated in an ambulatory/observation setting. 

Furthermore, according to MCG (Milliman Care Guidelines) Inpatient and Surgical Care 26th Edition cholecystectomy by laparoscopy, the operative status criteria is ambulatory. Thus, this patient should have been managed without an inpatient acute admission for this procedure. MCG also noted "that analysis of a cohort of 95,523 adult patients who underwent laparoscopic cholecystectomy within 10 days of presentation with acute cholecystitis found that 65% [percent] of the laparoscopic cholecystectomies were performed either the day of presentation (day 0) or the following day (day 1)." Thus, ambulatory status would have been appropriate.

Finally, MCG General recovery care 26th edition Ambulatory surgery exception criteria GRG:CG-AEC (ISC GRG) notes that a potentially ambulatory procedure or surgery warrants inpatient care due to 1 or more of the following: inpatient care needed for clinically significant preoperative disease or condition, complex surgical approach or situation anticipated, procedure is not low risk and patient at high anesthetic risk, presence of drug-related risk, inadequate outpatient care situation, postoperative event, condition, or finding that warrants inpatient stay. Given the above, the patient did not warrant inpatient status but ambulatory for this procedure as she did not warrant inpatient care as she did not have a significant preoperative disease or condition that warranted inpatient admission.

Finally, the reviewer is knowledgeable in this condition and the recommended health care services provided through actual clinical experience for this condition and therefore feels that the treatment provided was not justified at the inpatient admission level as the patient should have been managed in an ambulatory/observation setting. The reviewer does believe that based upon these findings the health care plan did act reasonably and with sound medical judgment. The criteria the reviewer has utilized included my own personal experience as to what constituted good acceptable standard of care, as well as the MCG guidelines as noted. Denial is upheld.

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

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