Appeal type: Medical necessity
Decision: Upheld

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

This is the case of an adult female who presented to the emergency department (ED) complaining of pain radiating to the back. She had positive hematuria and was advised to come to the ED. The nurse noted that she was complaining of pain radiating to the back since her gastric bypass. Vital signs were noted to be normal and the patient was afebrile. As per the ED provider note her exam revealed the abdomen to be soft non distended with positive periumbilical tenderness and negative Murphy's sign. White blood cells (WBC) were 7.62, serum glutamic-pyruvic transaminase (SGPT) 167, serum glutamic-oxaloacetic transaminase (SGOT) 118 and total bilirubin of 1.6. The assessment was probable biliary colic and the plan was labs and ultrasound. Computed tomography (CT) of the abdomen revealed gall bladder containing small amounts of hyperdense layering material which may represent previous sludge. There was no intrahepatic or extrahepatic ductal dilation. There was no evidence of free intraabdominal air or free fluid. The small bowel loops were not dilated. The impression was post-surgical changes of gastric bypass with no evidence of acute complication and possible biliary sludge.  The diagnosis was acute cholecystitis, acute abdominal pain and elevated bilirubin and transaminases. The patient's condition was stable.

The patient was taken to the operating room for robotic lap assisted cholecystectomy, and lysis of adhesions. No bile leak was noted on cholangiogram. 

Progress note indicated the patient was doing well and symptoms resolved. The plan was to discharge as per surgery. 

Based upon the records the inpatient admission was not justified as this patient should have been managed as noted by the insurer in an ambulatory/observation setting as she had an uneventful lap cholecystectomy for cholelithiasis. She did not have acute cholangitis and only had biliary colic and not acute cholecystitis. She did not have a significantly elevated WBC and she did not have a fever. She did have a cholecystectomy but this could have been done in an ambulatory/observation setting without an acute inpatient admission. 

This patient did not need to be admitted as she could have been managed on an outpatient/observation basis. She did not have any indication for acute inpatient admission. She did not have acute cholangitis, nor acute cholecystitis. She was seen in the ED and surgery was done and she went home. She had an uneventful robotic assisted lap cholecystectomy- all of which should have been done in observation setting as noted by the insurer. She did not need an acute inpatient admission. She did not have bowel obstruction as noted on the CT. There was no indication for acute care in this case. The patient should have been cared for with an ambulatory observation setting. 


Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for inpatient hospital stay is not substantiated.