Appeal type: Medical necessity
Decision: Upheld

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

The patient is a female who initially presented with concerns of near syncope and generalized weakness. Pertinent history included hypertension, gastroesophageal reflux disease, and hiatal hernia. Initial vital signs revealed a temperature of 36.8C. (Celsius), with a heart rate (HR) of 70 beats per minute (bpm), a blood pressure (BP) of 130/70 millimeters of mercury (mmHg), a respiratory rate (RR) of 18/minute, and a peripheral capillary oxygen saturation (SpO2) of 93% on room air. Initial examination documented the patient as awake, alert, and oriented with some tenderness in the right upper quadrant. An electrocardiogram (EKG) revealed normal sinus rhythm without acute ischemic changes. Initial laboratory testing revealed a white blood cell count (WBC) of 8.5, a hemoglobin of 11.8, platelets of 179, a sodium of 139, a potassium of 4.2, a blood urea nitrogen (BUN) of 16, a creatinine of 0.9, a calcium of 8.5, an alanine aminotransferase (ALT) of 252, an aspartate aminotransferase (AST) of 384, an alkaline phosphatase (ALP) of 152, and a Total bilirubin of 0.8. Troponins were negative x 2. A chest radiograph was unremarkable. A computed tomography (CT) of the abdomen/pelvis revealed findings suggestive of cholecystitis. Intravenous fluids were provided. The patient was placed in the hospital thereafter with an impression of syncope/near syncope due to vasovagal episode versus orthostasis, cholecystitis, and hypertension. The treatment plan included telemetry, thyroid panel, and a general surgery consultation. There were no new issues, and no recurrence of near syncope or syncope.  She was afebrile, and hemodynamics were stable. General surgery consultation was obtained whom recommended a hepatobiliary iminodiacetic acid (HIDA) scan. The HIDA scan was suggestive of biliary dyskinesia/cholecystitis. Abdominal pain had resolved. Liver function tests (LFT) were stable. General surgery offered a cholecystectomy this admission or in the outpatient setting. The laparoscopic cholecystectomy was performed without issue or complication. The patient was discharged.

At issue is the medical necessity for the inpatient hospital admission.

The health plan's determination of medical necessity is upheld, in whole.

Based on the clinical documentation provided, evidence based literature and standards of care, acute inpatient level of care was not indicated as medically necessary for the entire admission. Evaluation and management could have been performed at an alternate level of care.

The patient noted right upper quadrant tenderness in the setting of elevated transaminases. There was no fever or leukocytosis. Diagnostic testing revealed findings suggestive of cholecystitis. General surgery consulted, had an impression of biliary dyskinesia, and offered an inpatient or outpatient cholecystectomy. The cholecystectomy was performed during the hospitalization without issue or complication.

Moreover, clinical indications for admission to inpatient care were not met. The patient did not have acute cholangitis or suspicions for such. The patient did not have acute cholecystitis with systemic signs of inflammation (fever, C-reactive protein (CRP) > 10, WBC > 10,000). The patient did not have a common bile duct obstruction, persistent vomiting, persistent dehydration, hemodynamic instability, severe pain requiring intravenous (IV) analgesia more frequent than every 4 hours, signs of intestinal obstruction or peritonitis, or documented bacteremia. [4]