Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cholecystitis
Treatment: Inpatient Hospital Admission
The health plan denied the requested inpatient hospital admission as not medically necessary. 
The health plan's determination is upheld.

The patient is a previously healthy woman (9-months post-partum) who presented to the emergency department (ED) with upper abdominal pain and vomiting. At the time of presentation, the patient was without fever and vital signs were normal. She was tender in the right upper quadrant. The white blood cell count (WBC) count was normal at 10.8. The complete metabolic panel identified elevated liver enzymes and a normal bilirubin. Abdominal ultrasound and a computed tomography (CT) scan  showed gallstones within the gallbladder and gallbladder wall thickening. She was admitted to the hospital with the diagnosis of cholecystitis.
The patient was evaluated with surgery consultation. The patient underwent laparoscopic cholecystectomy. The operation was performed without complication. The diet was advanced following surgery and pain was controlled with oral medications. The patient remained clinically stable and was discharged from the inpatient setting with planned short term follow up.
At issue is the medical necessity for the requested inpatient hospital admission.

This patient is a woman who presented to the hospital with abdominal pain and vomiting. She was determined to have symptomatic cholelithiasis/cholecystitis. There is no documentation of hemodynamic, pulmonary, neurological, or metabolic reason for an acute inpatient level of care. There is no documentation of failure to achieve discharge criteria, conversion to open surgery, care for comorbidities, or any other condition requiring inpatient admission. The indication for cholecystectomy was established. The patient was admitted to the hospital. She underwent surgery to remove the gallbladder. The patient responded favorably to treatment and was stable for discharge from the hospital on the first post-surgical day with planned follow up. Acute inpatient care was not medically necessary for this patient as the care and treatment provided could have been rendered with an alternate level of care. A alternate level of care would have provided for ED assessment, surgical assessment and monitoring, laparoscopic cholecystectomy as performed, provision of intravenous (IV) antibiotics and fluid, and overnight care.
Milliman Care Guidelines (MCG) 26th ed Cholecystectomy by Laparoscopy (referenced in the health plan letter) state that the goal length of stay is observation, but that extended stay or inpatient care may be needed when there is:
Acute cholangitis with systemic signs of sepsis and evidence of common bile duct disease with bilirubin > (greater than) 2 milligrams/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, or acute cholecystitis (right upper quadrant (RUQ) pain or tenderness, systemic signs of inflammation, Cholecystectomy not anticipated due to high surgical risk or plan for 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, or gallstone ileus.
In this case, the patient presented with acute onset of upper abdominal pain. She responded favorably to initial treatment with antibiotics and surgical therapy and was stable for discharge from the hospital on the first day following surgery. The above MCG criteria did not exist in this case to warrant an inpatient level of care. An inpatient level of care was not medically necessary in this case. The care provided could have appropriately been rendered with an alternate level of care for this patient.