Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute cholecystitis and choledocholithiasis

Treatment: Inpatient admission 

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

This patient has a history of asthma, chronic obstructive pulmonary disease with oxygen dependency, coronary artery disease, chronic kidney disease, congestive heart failure, hypothyroidism, hypertension, and atrial fibrillation. She presented to the emergency department (ED) with complaints of jaundice, nausea, vomiting, and abdominal discomfort. Imaging tests determined the patient had acute cholecystitis and choledocholithiasis.

Acute cholecystitis and biliary complaints are a common inpatient diagnosis. Acute cholecystitis is also estimated to attribute to millions of ambulatory visits each year and is a leading cause of hospital admissions. [1] Studies have shown that ambulatory laparoscopic cholecystectomy is safe and avoids an overnight hospital stay. [2, 4, 5] Factors that contribute to admission after laparoscopic cholecystectomy include drain placement, conversion to open surgery, persistent abdominal pain, nausea, and vomiting. [3] In patients without abnormalities of the bile duct or abnormal liver function tests, ambulatory laparoscopic cholecystectomy is safe and feasible. [5] Ambulatory and/or outpatient laparoscopic cholecystectomies reduce hospital costs without compromising patient outcomes. [6]

Per clinical documentation, this patient presented to the ED (emergency department) with a two-day history of jaundice. There was associated nausea and decreased appetite. Vital signs in the ED were within normal limits. An ultrasound indicated cholelithiasis and a stone within the common bile duct. There were no signs of cholecystitis. The total bilirubin was elevated at 2.9. Alkaline phosphatase, alanine transaminase, and aspartate aminotransferase were all elevated at 169, 70, and 47, respectively. The white blood cell count was normal at 6.1. The patient had multiple comorbidities, including coronary artery disease, atrial fibrillation, and stent placement requiring the use of Plavix and Xarelto. The patient was evaluated by cardiology preoperatively. An endoscopic retrograde cholangiopancreatogram (ERCP) was performed due to the common bile duct stone and a papillotomy was performed. The patient underwent a laparoscopic cholecystectomy. There was excessive blood loss, and a Jackson Pratt (JP) drain was left due to the inflammation. The patient developed subsequent leukocytosis and an intraabdominal abscess. Infectious disease consultation was initiated along with intravenous antibiotics. The patient was noted to have abnormalities of the bile duct with associated abnormal liver function tests. The patient had surgical complications that necessitated further intervention and management.  

Per Milliman Care Guidelines (MCG) criteria, admission is indicated when common bile duct obstruction is indicated via imaging. [7] Inpatient stay is indicated after laparoscopic cholecystectomy if there is a severe infection. [8] Peer-reviewed literature and MCG criteria indicate that inpatient admission was medically necessary for this patient. Per provided clinical documentation, inpatient admission was medically necessary. 

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

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