Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Cholecystitis.
Treatment:  Inpatient admission.

The insurer denied coverage for inpatient admission.  The denial is overturned.

The patient is an adult who presented to the hospital with complaints of persistent abdominal pain that has been ongoing for 3 days.  The patient had been seen at the emergency department 2 days prior and was told that they had a stone in the gallbladder and possible cholecystitis.  The patient did not want surgery at the time and was discharged home with oral antibiotics and ibuprofen for pain.  Vital signs of the patient noted blood pressure of 145/80, temperature of 37.7 degrees Celsius, pulse of 116, and respirations of 17.  The physical exam findings noted right-sided abdominal tenderness.  Laboratory testing noted white blood cell count of 21.1, neutrophil of 74.2, hemoglobin of 10.9, platelets of 542, and carbon dioxide (CO2) of 21.3.  Surgery was consulted in the setting of increased leukocytosis and worsening pain.  Surgical consult advised the patient to be nothing by mouth with intravenous hydration.  The patient was to have hepatobiliary iminodiacetic acid (HIDA) scan, intravenous antibiotics, and pain management.  The patient received Zosyn intravenous every 8 hours.  The patient's pain was managed with acetaminophen, oxycodone, and hydromorphone.  The patient's symptoms improved.  The patient was deemed appropriate for discharge with follow-up for elective cholecystectomy in 1 to 2 weeks or sooner if needed. 

It was stated that the inpatient admission was medically necessary.  Excerpts from the medical record, physician documentation, and Milliman Care Guidelines (MCG) Guidelines were referenced.  Despite outpatient treatment of antibiotics and ibuprofen, the patient had worsened symptoms with chills and nausea.  The examination was notable for right-sided abdominal tenderness to palpation.  Surgery was consulted in the setting of increasing leukocytosis and worsening pain despite outpatient antibiotic use.  The patient was not stable for discharge.  The patient was admitted for acute cholecystitis.  There was an expectation that the inpatient stay would span over 2 midnights.  The patient was recommended to be nothing by mouth with intravenous hydration.  It would not have been feasible to obtain the medically necessary consultations and render the recommended medical care, with the necessary urgency at any other level of care.

Per the cited references, admission to the hospital for acute cholecystitis is recommended when there is right upper quadrant pain, mass, or tenderness, when there are systemic signs of inflammation as indicated by fever of at least 38 degrees, C-reactive protein level greater than 1, or white blood cell count greater than 10 or less than 4.  The documentation should detail that cholecystectomy is not anticipated due to high surgical risk or that interval cholecystectomy is planned.  The assessment included acute cholecystitis.  There was evidence of systemic signs of inflammation with white blood cell count greater than 10, and interval cholecystectomy was planned.  Thus, inpatient admission was medically necessary for the patient, per current literature and guidelines.  As such, the health care plan did not act reasonably, with sound medical judgement, and in the best interest of the patient.  Therefore, the denial of coverage for inpatient admission is overturned.  

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for inpatient admission is substantiated.