Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute Cholecystitis
Treatment: Inpatient hospital admission
The insurer denied coverage for inpatient hospital admission
The denial is overturned

This is the case of a female with no past medical history who presented to the Emergency Department (ED) with right upper quadrant (RUQ) pain, nausea and vomiting. The patient was seen in the ED 12 hours prior for left flank pain. Computed tomography (CT) and urinalysis were consistent with pyelonephritis, so the patient was discharged on antibiotics. However, during the day, she felt a new pain in the RUQ. The patient was admitted. As per the ED notes, the patient was seen earlier and discharged to home as she was diagnosed with a kidney infection and started on antibiotics. When she got home her abdominal pain increased and she began to vomit. The ED provider noted the patient was afebrile with stable vital signs; the abdomen was soft with abdominal tenderness in the RUQ and left costovertebral angle (CVA) tenderness. The patient was diagnosed with pyelonephritis last night and now returns with worsening pain and vomiting, without fever or chills. The patient was admitted to surgery for acute cholecystitis on RUQ sonogram. She was placed on intravenous (IV) antibiotics. Surgery noted that the patient was admitted with acute cholecystitis with a white blood cell (WBC) of 16. Liver function tests (LFT's) were normal. CT revealed cholelithiasis without ductal dilation. Abdominal sonogram showed positive Murphy's sign with abnormal distention of the gallbladder, with wall thickening and pericholecystic fluid.

She was taken to surgery for a lap cholecystectomy. Surgery was uneventful and a Jackson-Pratt (JP) drain was placed.  Post-op anesthesia assessment indicted the patient was stable without anesthetic complications. Post-op check indicated the patient was stable and denied nausea/vomiting. The assessment indicated the patient had two problems: left pyelonephritis and acute cholecystitis. The plan was to continue Ceftriaxone. Surgery saw the patient and noted no acute events. The plan was clear liquid diet and Ceftriaxone. The JP was to stay in.  Progress note documented no acute events. The patient was afebrile, and the patient tolerated clear liquid diet. Plan was to discharge today or tomorrow. The diet was advanced.  Infectious Disease saw the patient and noted to continue the Ceftriaxone. Infectious Disease saw the patient later and noted the flank pain was much better. The patient denied nausea/vomiting and recommended to discontinue Ceftriaxone and place on oral antibiotics. Infectious Disease signed off from the case. The patient was cleared for discharge.

This patient did have signs and symptoms for acute cholecystitis. She did have a WBC elevation; she did have right upper quadrant tenderness with positive Murphy's sign as well as gallbladder wall thickening and pericholecystic fluid. In addition, she did have pyelonephritis which added to the treatment picture for her. Milliman Care Guidelines (MCG) Inpatient and Surgical Care 25th Edition cholecystectomy by laparoscopy notes that the operative status criteria is ambulatory. However, this patient did require being in the hospital for this procedure due to the care that she required post-surgery.

In this case, the patient needed IV hydration due to the cholecystitis as well as persistence of pain. Thus, justification for inpatient admission can be seen for this patient.

The full inpatient admission was justified as the patient did have acute cholecystitis and indication for an inpatient admission due to the need for IV antibiotics for her pyelonephritis as well as IV hydration. The patient required inpatient admission due to the two diagnoses elevated WBC in the setting of RUQ pain for acute cholecystitis, and CVA tenderness for the pyelonephritis.

The healthcare plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The insurer's denial of coverage for the inpatient hospital admission is reversed. Medical necessity is substantiated.