Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cholelithiasis. 
Treatment: Inpatient Hospital Admission. 

The insurer denied coverage for inpatient hospital admission. 

The denial is upheld. 

This is the case of a female with history of supraventricular tachycardia (SVT), gastritis, and irritable bowel syndrome. She presented to the ER (emergency room) with complaints of abdominal pain. The patient was afebrile with stable vital signs. As per the ED (emergency department) nurse the patient complained of abdominal pain and was admitted.  The ED provider notes indicated the patient complained of abdominal pain. The patient denied past medical history of gall stones. Exam revealed the abdomen to be soft, non-distended with epigastric and RUQ (right upper quadrant) tender to palpation without rebound or guarding. 

General surgery noted in history and physical that the patient had abdominal pain for 1 day which localized to the epigastric and RUQ region. It had progressively worsened which prompted her visit to the ED. She denied fever, chill. Her WBC (white blood cell) was 11.1, bilirubin was normal, and AST (aspartate transaminase) was 104 and ALT (alanine transaminase) was 57 (mildly elevated). Ultrasound of the abdomen revealed cholelithiasis and sludge in a mildly distended gallbladder with positive Murphy sign. The findings were suggestive of acute cholecystitis. On exam, she was afebrile with tenderness to the epigastric and RUQ without rebound or guarding. The assessment was acute cholecystitis, and the plan was to admit to surgical floor, NPO (nothing by mouth), and IV (intravenous) antibiotics. 

The acute inpatient admission was not justified as this patient could have been managed as noted by the insurer in an ambulatory/observation setting as she had an uneventful lap cholecystectomy. 

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% 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. Given the above the patient did not warrant inpatient status but ambulatory for this procedure as she did not warrant inpatient care. 

The admission was not justified at the inpatient admission level as the patient should have been managed in an ambulatory/observation setting. 

The health care plan did act reasonably and with sound medical judgment. 

Denial is upheld. 

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 hospital admission is upheld. Medical Necessity is not substantiated.