Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal pain.

Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is overturned.


The patient is an adult male with no significant past medical history who presented with diffuse abdominal pain. In the emergency department, he was noted to have uncontrolled hypertension, requiring intravenous anti-hypertensives. He also developed acute respiratory failure with oxygen saturations of 88% on room air which improved with appropriate therapy and pain control. Cardiology consultation was obtained, and an echocardiogram was performed. 

Upon presentation to the Emergency Department (ED), he was noted to be hypertensive.  Oxygen saturation was 96% on room air. Laboratory studies were unremarkable. A venous blood gas showed an elevated lactic acid of 2.8 and pO2 (pressure of oxygen) of 49. While in the Emergency Department (ED), the patient became tachypneic. He desaturated to 88% on room air and was placed on 6 liters of oxygen, with improvement in his oxygen saturations to 95%. A STAT (immediate) chest X-ray was performed, demonstrating an elevated right hemidiaphragm, a likely underlying pleural effusion, and concern for pulmonary edema. His respiratory status improved with intravenous (IV) Lasix and pain medication. Ultrasound of the right upper quadrant showed a mildly hydroptic gallbladder filled with sludge, small pericholecystic fluid, and small amount of fluid in the right lower quadrant, suspicious for acute cholecystitis. X-ray of the abdomen showed ileus pattern present, with hazy opacities at the bilateral lung bases. Computerized tomography (CT) of the abdomen and pelvis showed a dilated gallbladder with cholelithiasis and mild surrounding fat stranding highly suspicious for acute cholecystitis. It was suspected that the hypoxia, tachypnea, and increased work of breathing was secondary to severe abdominal pain with resulting splinting and aggravated by bilateral atelectasis. 

The patient's hemodynamic and respiratory status stabilized by day two. A trans-thoracic echocardiogram (TTE) demonstrated significant left ventricular hypertrophy and a left ventricular ejection fraction of 55%. Once stable he underwent a laparoscopic cholecystectomy for acute gangrenous gallbladder. Following the surgery, he was difficult to extubate, and critical care consultation was obtained. 

Although the surgery was uncomplicated, this patient required intensive monitoring and treatments to ensure his hemodynamic, cardiac, and respiratory stability. 

Ripetti et al (2019) examined the predictive factors aimed at facilitating cholecystectomy in a day surgery setting. These authors retrospectively examined 985 consecutive patients who underwent elective laparoscopic cholecystectomy for gallstone disease between May 2006 and February 2015. These patients were divided into two groups: group A with a length of stay <= 2 days (922 patients) and group B with a length of stay > 2 days (63 patients). Univariate analysis determined that age, sex and the presence of obesity, cardiac, and renal comorbidities were associated with an increased likelihood of a longer hospital stay. The logistic regression model showed that only age was a significant predictor of a longer stay. No specific complication reached statistical significance in extending the length of stay in group B. These authors concluded that prolonged length of stay following laparoscopic cholecystectomy is related to the patient's comorbid medical conditions. 

Based on the above, the insurer's denial must be reversed. 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 hospital admission is substantiated.