Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Cholecystitis
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay
The determination is upheld.

The patient presented to the hospital emergency department (ED) with recurrent episodes of biliary colic/cholecystitis, nausea and vomiting. Comorbid health conditions included hypertension and cocaine abuse. She was hemodynamically stable at the time of presentation. The white blood cell (WBC) count was 8.3 thousand (K). An ultrasound identified gallstones, no pericholecystic fluid, and a gallbladder wall thickness of 1.7- millimeters (mm). She underwent laparoscopic cholecystectomy and primary tissue repair of an umbilical hernia. The operative dictation describes an inflamed gallbladder with intraluminal gallstones. The anesthesia record documents stability during procedure. She was treated with intravenous (IV) fluid in the recovery area and was admitted to the hospital for overnight observation. She remained clinically and hemodynamically stable during the period of monitoring. The patient was started on a diet following surgery.
The patient was treated with post-surgical monitoring, IV fluid, IV analgesia, and antiemetics. The immediate post-surgical recovery was uncomplicated. The post-operative note states that she was comfortable in bed, was walking, had stable vital signs and tolerated the liquid diet overnight. Following surgery and the initial recovery period, the patient had stable vital signs. Pain was controlled. The diet was advanced.
The patient remained clinically stable and was discharged from the inpatient setting. At issue is the medical necessity of an inpatient stay.

No. An inpatient level of care was not medically necessary in this case. This patient is a patient who presented with cholelithiasis/cholecystitis. There is no documentation of hemodynamic, pulmonary, neurological, or metabolic reason for an acute inpatient level of care at the time of presentation. This patient was admitted to the hospital on with symptomatic gallstones. She underwent an uncomplicated procedure to remove the gallbladder. This operation was completed and there were no peri-operative complications or other clinical issues that mandated inpatient admission and care. She remained stable and was discharged from the hospital on the day following surgery.
Pre-surgical assessment, the surgical procedure and perioperative IV fluid, IV antibiotics, IV antiemetics, and post-surgical monitoring could have been provided at a lower level than inpatient. The patient was clinically stable following surgery as supported by the corresponding medical records. Inpatient stay related to cholecystectomy may be needed for failure to achieve discharge status criteria, conversion to open surgery, systemic infection, care for active comorbidities, complications of procedure. In this case, none of these indications existed to justify an inpatient level of care. The concomitant suture repair of an umbilical hernia did not substantially alter this patient's recovery and did not require inpatient care.
The perioperative period was uncomplicated and there is no documentation of failure to achieve discharge criteria, conversion to open surgery, care for comorbidities, procedural complications, or any other condition requiring inpatient admission. The patient was discharged from the hospital on the day following surgery after being monitored overnight.
Based on the submitted clinical documentation, an inpatient level of care was not medically necessary.