Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cholecystitis.

Treatment: Inpatient admission.

The insurer denied the inpatient admission.

The denial was upheld.

This is a female patient with no medical history. She presented to the Emergency Department (ED) with complaints of right upper quadrant (RUQ) pain for the past week.  She was referred to the ED by her primary care physician for a gallstone in the neck of the gallbladder. She was seen in the ED by the triage nurse who noted that the patient had pain for 1 week and was seen by her Primary Care Physician (PCP) who referred her for rule out cholecystitis. She was consulted by surgery and made nothing by mouth (NPO). On exam she was afebrile with stable vital signs with the abdomen soft, non-distended with tenderness in the RUQ without rebound or rigidity. The plan was intravenous (IV) fluids, pain medications and ultrasound of the gallbladder.  Ultrasound of the abdomen showed gallstone with possible ancillary findings of cholecystitis. 

General surgery saw the patient and admitted the patient and noted on exam negative Murphy sign. The patient was afebrile with normal vital signs.  The white blood cell (WBC) count was 7.8.  There was minimal tenderness to deep palpation in the RUQ. The patient was stable with non-tender abdomen and the patient was discharged with plan for interval cholecystectomy. 

According to MCG Health Inpatient and Surgical care- 24tth edition Gall bladder or bile duct inflammation or stone ORG: M-555 (ISC) clinical indications for admission to inpatient care may include patients with 1 or more of the following: Acute cholangitis as indicated by ALL of the following: Systemic signs of inflammation indicated by 1 or more of the following: Fever, C-reactive protein level greater than 10 mg/L, White blood cell count greater than 10,000/mm3 (10 x109/L) or less than 4000/mm3 (4 x109/L); Evidence of common bile duct disease indicated by 1 or more of the following: Total serum bilirubin level greater than or equal to 2 mg/dL (34 micromoles/L), Liver function test (alkaline phosphatase (ALP), r-glutamyl transferase (GGT), aspartate aminotransferase (AST), or alanine aminotransferase (ALT)) greater than 1.5 times the upper limit of normal, Hepatobiliary imaging showing biliary dilatation or evidence of etiology (e.g., stricture, stone, previously placed stent);   Acute cholecystitis as indicated by ALL of the following: Right upper quadrant pain, mass, or tenderness; Systemic signs of inflammation indicated by 1 or more of the following: Fever, C-reactive protein level greater than 10 mg/L, White blood cell count greater than 10,000/mm3 (10 x109/L) or less than 4000/mm3 (4 x109/L); Cholecystectomy not anticipated (i.e., within subsequent few days) due to 1 or more of the following: High surgical risk (e.g., severe comorbidities, organ failure), Interval cholecystectomy planned (i.e., not during current hospitalization); Calculus or obstruction of gallbladder or bile duct and 1 or more of the following: hemodynamic instability, Common bile duct obstruction diagnosed (e.g., by imaging), vomiting that is severe or persistent, dehydration that is severe or persistent, severe pain requiring acute inpatient management, bacteremia.  

This patient did not have signs and symptoms for acute cholecystitis as she only had RUQ pain in the setting of a normal WBC.  She did not have fever or any systemic sign of acute inflammation to warrant an acute admission.  She was also not persistently vomiting, and she was able to tolerate clears. She could have been treated in an observation setting and sent home on oral antibiotics if necessary.  

Based upon these findings the health care plan did act reasonably and with sound medical judgment; the patient did not require inpatient admission.

The carrier's denial of coverage for the hospital admission is upheld.  The medical necessity is not substantiated.