Appeal type: Medical necessity
Decision: Overturned

Cholecystitis /Inflammation of Gallbladder
Inpatient Hospital

The patient is a female with history of prematurity and a Neonatal Intensive-Care Unit (NICU) stay with prolonged total parenteral nutrition (TPN) as a neonate, and only other past medical history of constipation.

The patient presented with abdominal complaints, elevated liver function tests (LFTs) and found to have a solitary gallstone on ultrasound (U/S) imaging. She was admitted and taken to the operating room (OR) the next day for laparoscopic cholecystectomy where findings were consistent with (c/w) acute cholecystitis and cholelithiasis.
The child was categorized as American Society of Anesthesiologists (ASA) 1. There was no concurrent comorbidity other than constipation and no history of (h/o) persistent disease of prematurity. It was a straightforward operation lasting 1 hour and 17 minutes.
The patient did well overnight and was discharged in good condition the following day.
The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is overturned.

Yes, an inpatient hospital admission was necessary. This is an unusual procedure in a patient of this age, with risk of complications. An inpatient stay is justified due to the general anesthetic and invasive procedure, and expectation of possible ileus for 1-2 days given the inflammatory nature of the primary disorder (cholecystitis with edema surrounding the gallbladder). Monitoring of patient condition including vital signs and urine output every 4 hours would be expected.

An intermediate or critical level of care cannot be justified in this case, but would be justified if there were additional complicating factors (e.g., cholecystitis with biliary obstruction or cholangitis, choledocholithiasis, pancreatitis), an untoward perioperative event, intraoperative injury or complication, inadequate physiologic recovery, hemodynamic instability, other acute organ injury, altered mental status, fever or other signs of septic complications, surgical site complication, management of complex comorbid medical condition or a finding of an occult or new medical condition. A lower level of care status could be justifiable if the cholecystectomy was performed for simple biliary colic. No evidence presented in the appeal documentation or in the primary medical records that would indicate that an intermediate or critical level of care was justified or necessary.

Surgical treatment of otherwise healthy pediatric patients with acute biliary colic or acute cholecystitis could be provided at a lower level of care status. In this case, with only elevated liver function tests and cholecystitis, the most appropriate level of care that can be justified based on the condition of the child is acute inpatient level of care.
Indeed, in one study authored by Daodu et.al., in Journal of Pediatric Surgery in September of 2019, encompassing over 64,000 cases, the average length of stay was 3.44 days. The prevalence of septic complications was low at 0.09%, readmissions were documented in only 1.4%, and bleeding requiring transfusion was seen in 0.2%. Surgical site infections were seen in 0.8%. So, while true complications were low, the length of stay was about 3 days on average, suggesting a complexity to the cases that required inpatient care and monitoring to optimize outcomes.

Thus, based on the literature and widespread experience with modern treatment of pediatric acute cholecystitis, an inpatient acute level of care is justified. Some patients may have evidence of physiologic compromise that would indicate medical necessity for an even higher level of care, and if so, this evidence should be seen in the medical records.