Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute Cholecystitis

Treatment: Inpatient hospital admission 

The insurer denied the inpatient hospital admission. 

The denial was upheld.  

This is a male patient with past medical history of hypertension (HTN). He presented to the emergency department (ED) with complaints of abdominal/epigastric pain, fever and nausea and vomiting for a couple of days. The pain radiated to the right upper quadrant (RUQ). The patient had a sonogram at an urgent care center with findings of gallstones. Exam revealed the abdomen to be soft with RUQ tenderness and Murphy's sign. No guarding or rebound was noted. The patient was afebrile. His white blood cell count was 15.88.  An abdominal ultrasound was performed that showed distended gall bladder containing a calculus. The wall was mildly thickened with a small amount of pericholecystic fluid. There was also a positive sonographic Murphy's sign with the findings compatible with acute cholecystitis. The plan was to admit to surgery and underwent an uneventful laparoscopic cholecystectomy. He was treated with intravenous antibiotics and his diet was advanced as tolerated. He was medically stable and discharged home. 

According to MCG Health Inpatient and Surgical care- 24th 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: 1) 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); or  2) 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: Finally, MCG Health - Inpatient and Surgical care 24th edition. Cholecystectomy by laparoscopy ORG: S-365 (ISC) noted that  Procedure is indicated for 1 or more of the following: Symptomatic gallstone disease as indicated by ALL of the following: Evidence of gallstone disease as indicated by 1 or more of the following: Stones demonstrated on cholecystography, ultrasound, CT, or MRI, Non-visualizing gallbladder with double-dose cholecystography or HIDA scan, Symptoms of gallstone disease as indicated by 1 or more of the following: Biliary colic; Acute cholecystitis as indicated by ALL of the following: Right upper quadrant pain, mass, or tenderness, Systemic signs of inflammation as 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).  

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

Based on the above, the medical necessity for the inpatient hospital admission is not substantiated.  The insurer's denial is upheld.