Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Symptomatic cholelithiasis.

Treatment: Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission.

The denial is upheld. 

This is a female patient with a past medical history of anemia, chronic back pain, non-Hodgkin's lymphoma currently in remission and status post Caesarean section who was taken to the Emergency Department (ED) via emergency medical services (EMS) with complaints of right upper quadrant (RUQ) abdominal pain radiating to the back. The patient was afebrile with stable vital signs. As per the ED provider, on examination, the patient had RUQ tenderness and the impression was acute cholecystitis due to biliary calculus. The patient was admitted for symptomatic cholelithiasis with possible choledocholithiasis.

The patient's liver function tests (LFTs) were normal. Her white blood cell (WBC) count was 7.11. An ultrasound of the gallbladder revealed a distended gallbladder with cholelithiasis and sonographic Murphy's sign. These findings raised the suspicion for acute cholecystitis with normal gallbladder wall thickness. The common bile duct (CBD) was dilated with 2 millimeters echogenic focus in the distal CBD suggesting choledocholithiasis. The plan was to admit to general surgery and plan for magnetic resonance cholangiopancreatography (MRCP); and if negative for choledocholithiasis then the plan was for laparoscopic cholecystectomy. If MRCP was positive, then they would get a Gastroenterology (GI) consult for Endoscopic retrograde cholangiopancreatography (ERCP). The MRCP was negative for choledocholithiasis and the plan was for surgery. The patient underwent an uneventful laparoscopic cholecystectomy on day 2 of admission. The patient had remained overnight post laparoscopic cholecystectomy for pain control which improved on day 3 of admission and the patient was discharged.

The medical necessity of inpatient admission was not justified at an acute level of care as this patient did not have acute cholecystitis that required an inpatient admission. She did not have a significantly elevated WBC or a fever or an ultrasound that documented any findings consistent with acute cholecystitis except for a positive Murphy's sign. There was neither gallbladder wall thickening nor any pericholecystic fluid. She had normal LFTs. The laparoscopic cholecystectomy could have been done under an observation setting. All of this could have been done as noted by the insurer under an observation status. And as noted by the insurer she did not meet Milliman Care Guidelines (MCG) criteria for inpatient admission.

Furthermore, according to the guidelines of MCG Health Inpatient and Surgical care- 24th edition Gall bladder or bile duct inflammation or stone, the goal length of stay is ambulatory or 2 days and assumes optimal recovery, decision making, and care. Patients may be discharged to a lower level of care (either later than or sooner than the goal) when it is appropriate for their clinical status and care needs. She did not have indications for acute inpatient admission as per MCG. In addition, MCG Inpatient and Surgical Care 24th Edition cholecystectomy by laparoscopy notes that the operative status criteria is ambulatory. Thus, this patient could have had the cholecystectomy done in an ambulatory/observation care setting and did not meet criteria for admission.

Finally, a Cochrane review concluded "Day-surgery appears just as safe as overnight stay surgery in laparoscopic cholecystectomy." 

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

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