Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute cholecystitis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld.

This is a female patient who presented to the Emergency Department (ED) with complaints of abdominal pain. The documentation indicated that the patient woke up that morning complaining of upper abdominal pain followed by multiple episodes of vomiting.  The patient did not have any significant comorbidity.  Upon physical examination, the patient had a temperature of 97.6 degrees with a heart rate of 88 beats per minute. The patient's blood pressure was 123/70 with oxygen saturation at 100%. The patient did not have any evidence of abdominal distention or rebound tenderness. The recommendation was made for laboratory diagnostic studies. The patient underwent a chest x-ray revealing no evidence of acute cardiopulmonary disease. The patient underwent an ultrasound of the abdomen revealing a gallstone within the neck of the gallbladder, possibly impacted. The gallbladder was distended measuring 10 cm and the gallbladder wall was thickened measuring 3.8 mm. The imaging findings reflected possible acute cholecystitis.  

The documentation indicated that the patient was initially treated with morphine as well as Zofran and a liter of normal saline. Upon reexamination, the patient was in no acute distress. Ongoing treatment included intravenous (IV) fluids. Additional reassessment indicated that the patient was feeling better after receiving medication. There continued to be tenderness upon physical examination to the right upper quadrant. The documentation detailed that the patient was recommended to be admitted. The patient was recommended to undergo surgical consultation, and on the following day, the patient underwent a laparoscopic cholecystectomy. The patient had some bradycardia with a heart rate of 46-48 beats per minute and borderline blood pressures in the 100/50s; however, the patient remained asymptomatic.  The patient continued to advance her diet and her pain was controlled. There were no further adverse events and she was discharged on day 2 of admission with instructions to follow-up.

According to Milliman Care Guidelines (MCG), a patient may be appropriate to be admitted to an inpatient status when there is evidence of acute cholecystitis as evidenced by right upper quadrant pain, mass or tenderness and systemic signs of inflammation as evidenced by fever, and elevated c-reactive protein (CRP) greater than 10 mg/L or a white blood cell count greater than 10,000. Additionally, if there is evidence of obstruction of the gallbladder or bile duct, the patient may be admitted. In this case, the submitted documentation for review does not support these criteria for inpatient admission. Though the patient's imaging revealed the possibility of acute cholecystitis, the patient's symptoms were responsive to medication. While the patient was admitted and underwent surgical intervention, there is no indication that she needed an inpatient level of care. As such, given the evidence of hemodynamic stability and a lack of the above clinical indications for inpatient level of care, inpatient admission was not medically necessary for this patient. 

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

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