Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient Admission
The insurer denied the inpatient admission.
The health plan's determination is upheld.

The patient is a female who presented to the hospital with complaints of abdominal pain of 1-day in duration. Her vital signs were normal at the time of presentation. She had tenderness in the right upper quadrant. The white blood cell count (WBC) count was normal and her liver enzymes and bilirubin were normal.
Her ultrasound on showed gallstones in the gallbladder and wall thickening, consistent with acute calculus cholecystitis. She was admitted to the hospital and was started on intravenous (IV) antibiotics. The surgical history and physical (H&P) state that the patient had cholecystitis for which a laparoscopic cholecystectomy was already scheduled for the same day that the patient was admitted. The surgery was performed on the day of admission. The operative notes describe an acutely inflamed gallbladder. The laparoscopic cholecystectomy was performed without complication.
On the following day the patient's diet was advanced and her pain was controlled with oral medications. The patient's vital signs were normal. The patient remained clinically stable and was discharged from the inpatient setting the day after surgery.
The health plan letter references the Milliman Care Guidelines (MCG) Cholecystectomy by Laparoscopy, 25th ed.

The health plan in its determination of medical necessity acted reasonably, with sound medical judgment and in the best interest of the patient. An inpatient level of care was not medically necessary in this case. This patient presented to the hospital with a complaint of abdominal pain. Imaging and a surgical consultation were performed on the day of admission and established the diagnosis of cholelithiasis/cholecystitis.

The inpatient admission was not medically necessary in this case. The care provided could have been rendered at an alternate level of care. An alternate level of care would have provided for the initial assessment, perioperative care and monitoring, provision of intravenous (IV) fluids, surgical consultation, performance of the cholecystectomy, and overnight care. There were no peri-procedure complications or other clinical issues.

Inpatient care (according to the referenced Milliman Care Guidelines (MCG)) may be needed when there is:
Acute cholangitis with systemic signs of sepsis and evidence of common bile duct disease with a bilirubin greater than (>) than 2 milligrams per deciliter (mg/dl) or aspartate aminotransferase (AST)/alanine aminotransferase (ALT) 1.5 times upper limit of normal, or imaging showing biliary dilatation or evidence of etiology.
For acute cholecystitis, right upper quadrant (RUQ) pain or tenderness and systemic signs of inflammation, a cholecystectomy may not be anticipated due to a high surgical risk or a plan for an interval cholecystectomy.

Also, criteria for inpatient admission may include:

Failure to achieve discharge criteria

Conversion to open surgery

Severe post-operative infection

Care for active comorbidities

Complications of procedure

Gallstone ileus.

In this case, the patient presented with cholelithiasis/cholecystitis. Her evaluation and the indication for a cholecystectomy was completed and established on the day of admission. The patient's laboratory data was normal. The cholecystectomy procedure was performed without complications and the patient was stable for discharge from the hospital on the first post-procedure day. These conditions did not warrant an inpatient level of care. The patient's presenting condition at the hospital, laboratory data and the clinical course did not justify an inpatient level of care. The care provided could have appropriately been rendered at an alternate level of care.