Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute cholecystitis.
Treatment: Inpatient admission.
The insurer denied coverage for inpatient admission.
The denial is upheld.

This is the case of an adult with a past medical history (PMH) of a laparoscopic appendectomy who presented to the emergency room (ER) with complaints of abdominal pain. As per the ER triage note, the patient presented with right-sided stomach pain with nausea and abdominal pain. The patient was afebrile with stable vital signs. As per the ER provider note, the patient presented with 1 day of right upper quadrant (RUQ) pain associated with nausea but no vomiting. The patient denied fevers or diarrhea. Exam revealed RUQ tenderness. The plan was computed tomography (CT) with the principal diagnosis of acute cholecystitis. CT revealed suspected mild gallbladder wall thickening and question trace inflammation. Ultrasound was recommended for further evaluation. Ultrasound revealed hepatic steatosis and hepatomegaly with an area of focal fatty sparing near the gallbladder. The gallbladder was within normal limits with a few low-level internal echoes which may represent sludge. There was no wall thickening or pericholecystic fluid. The common bile duct measured 6 millimeters (mm). Labs included white blood cells (WBC) 7.59, total bilirubin 0.6, aspartate transaminase (AST) 25, alanine transaminase (ALT) 75 and alkaline phosphatase (Alk Phos) of 89.

The patient underwent an uneventful laparoscopic cholecystectomy with cholangiogram with findings of free flow into the duodenum. Pathology revealed subacute and chronic cholecystitis. Orthopedics saw the patient and noted a non-displaced distal radius fracture and reported that the patient was stable for discharge from an orthopedic perspective. The post operative note indicated the patient was doing well with pain well- controlled. The plan was to advance the patient's diet as tolerated, get out of bed (OOB) and ambulate. The progress note indicated the patient was doing well, tolerating a diet and resting comfortably. The plan was to discharge that day if vitals were within normal limits and the patient tolerated a regular diet. The patient was discharged.

According to the guidelines of Milliman Care Guidelines (MCG) Health Inpatient and Surgical Care- 26th edition Gall bladder or bile duct inflammation or stone, patients may be discharged to a lower level of care (either later than or sooner than the goal) when it is appropriate for their clinical status and care needs.

Based upon the submitted records, the patient did not have acute cholecystitis, but rather biliary colic for which an elective laparoscopic cholecystectomy was needed. An acute inpatient admission was not medically necessary. This patient could have been managed as noted by the insurer in an ambulatory/observation setting as the patient had an uneventful laparoscopic cholecystectomy.

The health care services provided through actual clinical experience for this condition was not justified at the inpatient admission level as the patient should have been managed in an ambulatory/observation setting.

The health plan acted reasonably, with sound medical judgment and in the best interest of the patient.

The insurer's denial of coverage for the inpatient admission is upheld. Medical necessity is not substantiated.