Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain s/p (status/post) robotic assisted cholecystectomy
Treatment: Inpatient admission
The insurer denied coverage for: Inpatient admission
The denial is: Upheld
This is the case of a patient who presented to the emergency department (ED) with 3 hour history of upper abdominal pain. The ED provider note states the patient has a past medical, family, social history (PMHX) of Hepatitis C, hypertension (HTN), and cholelithiasis and was seen a few months ago in the ED and had a planned elective cholecystectomy in 2 days. The patient was afebrile with stable vital signs. The abdomen was soft with right upper quadrant (RUQ) tenderness. Labs were remarkable for: elevated transaminases 3 times normal bilirubin, and concerned was raised for choledocholithiasis and cholecystitis. Lipase 224, white blood cell count (WBC),  5.1k (thousand), aspartate aminotransferase (AST)  846, and alanine transaminase (ALT)  393. 

Sonogram showed cholelithiasis with no biliary dilation with the common bile duct (CBD) measuring 0.4 millimeter (mm) with no evidence of acute cholecystitis. Pancreas was visualized and was normal. Infectious Disease (ID) consulted and noted the lipase was now normal. The pain had diminished and the patient reported no vomiting or nausea. ID felt that acute biliary colic has resolved and advised to continue antibiotics. 

Patient was scheduled for surgery but the case was cancelled as no blood was available. Patient underwent an uneventful robotic assisted lap cholecystectomy two days later. Of note the operative note indicated choledocholithiasis and there was no evidence that any procedure was done for this in the operating room. 

The patient had severe abdominal pain in the epigastric area 10/10. Sonogram of the gallbladder showed gallstone. The patient was seen by ID who recommended Cefoxitin. The patient underwent robotic assisted cholecystectomy because of symptomatic choledocholithiasis, choledocholithiasis in setting of multiple attacks of symptomatic gallstone and a history of admission for gallstone pancreatitis. Post operatively the patient was monitored and discharged in stable condition. Per the appealer, the inpatient admission was needed for this patient who needed close monitoring and surgical management. 

Based upon the records I do feel that the acute inpatient admission was not justified as this patient should have been managed as noted by the insurer in an ambulatory/observation setting as the patient had an uneventful laparoscopic cholecystectomy for biliary colic and did not have acute cholecystitis and did not have choledocholithiasis. This patient had biliary colic and needed the gallbladder to be taken out (on the planned date). This surgery however is an ambulatory procedure. The patient should have had the gallbladder taken out and then sent home within a 23 hour observation period. The surgery was being done without any evidence of proven choledocholithiasis and in fact if the surgeon felt there was common duct stones he should have done at least an intraoperative cholangiogram. 

Finally, MCG General recovery care 27th edition Ambulatory surgery exception criteria GRG:CG-AEC (ISC GRG) 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. 

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 the inpatient admission from is not substantiated.