Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Chronic Cholecystitis.
Treatment:  Inpatient admission.

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

This is the case of an adult male with history of a hyperlipidemia (HLD) who presented to the emergency department (ED) with epigastric pain. The pain came on suddenly overnight. As per the surgical History and Physical, he has had a few episodes in the past, but this was the most severe. He had associated nausea and self-induced vomiting. He denied fevers and chills. Liver function tests (LFTs) showed a T (total) Bilirubin/D (direct) Bilirubin of 2.0/1.4 and AST/ALT (aspartate transaminase/ alanine transaminase) of 1017/752. White blood count (WBC) was 4.3. On exam, he was afebrile and had a soft non-distended abdomen with tenderness in the right upper quadrant (RUQ) and negative murphy's sign. Sonogram noted intrahepatic ductal dilation; common bile duct borderline distended up to 7 mm (millimeters) in diameter; distended gallbladder with mild wall thickening and mobile stones; no pericholecystic fluid and no sonographic Murphy's sign. The assessment was choledocholithiasis and the plan was to trend LFT's, magnetic resonance cholangiopancreatography (MRCP) and possible lap cholecystectomy. Antibiotics and Zofran were to be given with intravenous (IV) fluids.

Progress notes indicated the patient was NPO (nothing by mouth) and had no acute events overnight. The patient denied having abdominal pain, nausea or vomiting. The patient was afebrile. Liver function tests indicated of 508/693, respectively. Bilirubin total was 1.7 and WBC was 5.9.

The patient was taken to the operating room and had a laparoscopic cholecystectomy, which was uneventful. Pathology revealed chronic cholecystitis and cholelithiasis. Progress indicated the patient was doing well and the plan was discharge to home.

Acute inpatient admission was not justified as this patient could have been managed in an ambulatory/observation setting, as he had an uneventful lap cholecystectomy following the passage of a stone. He did not have acute cholangitis; he had biliary colic with the passage of a stone. He did not have an elevated WBC and he did not have a fever. He did have elevated liver function tests which were returning to normal without surgery. He did merit having his gall bladder taken out, but this could have been done in an ambulatory/observation setting. This was not acute cholecystitis, and, therefore, did not need an acute inpatient admission. 

Milliman Care Guidelines (MCG) Inpatient and Surgical Care 26th Edition cholecystectomy by laparoscopy the operative status criteria is ambulatory. Thus, this patient should have been managed without an inpatient acute admission for this procedure. MCG also noted "that analysis of a cohort of 95,523 adult patients who underwent laparoscopic cholecystectomy within 10 days of presentation with acute cholecystitis found that 65% (percent) of the laparoscopic cholecystectomies were performed either the day of presentation (day 0) or the following day (day 1)."  Thus, ambulatory status would have been appropriate.

MCG General recovery care 26th edition Ambulatory surgery exception criteria notes that potentially ambulatory procedure or surgery warrants inpatient care due to 1 or more of the following: Inpatient care needed for clinically significant preoperative disease or condition; Complex surgical approach or situation anticipated; Procedure is not low risk and patient at high anesthetic risk; Presence of drug-related risk; Inadequate outpatient care situation; Postoperative event, condition, or finding that warrants inpatient stay. 

The admission 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 in the best interest of the patient.

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