Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cholelithiasis/cholecystitis 
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient presented to the emergency department (ED) with intermittent abdominal pain. He has no significant past medical history. At the time of presentation, the patient was without a fever, his heart rate was 84 and blood pressure was 131/81 millimeters of mercury (mmHg). He had tenderness in the right upper abdomen. The white blood cell count (WBC) count was 14 thousand (K). The complete metabolic panel identified elevated serum transaminases with normal bilirubin. An abdominal ultrasound showed gallstones, gallbladder wall thickening of 2.5 millimeters (mm), and a normal caliber common bile duct.
The patient underwent a laparoscopic cholecystectomy with cholangiogram. The operative dictation describes cholecystitis. He was clinically stable following surgery and was treated with post-surgical monitoring, intravenous (IV) fluid, IV analgesia, and antiemetics. The immediate post-surgical recovery was uncomplicated. On post-operative day #1 following surgery, the patient had stable vital signs. The pain was controlled with oral medications. The diet was advanced. The patient remained clinically stable and was discharged from the inpatient setting.
At issue is the medical necessity of an inpatient stay.
An inpatient level of care was not medically necessary in this case.
This patient was admitted to the hospital with the diagnosis of cholelithiasis/cholecystitis. The indication for cholecystectomy was established. The patient underwent an uncomplicated laparoscopic cholecystectomy procedure. There were no peri-operative complications or other clinical issues. He remained stable and was discharged from the hospital.
A lower level of care would have permitted for the pre-surgical assessment, the surgical procedure, and perioperative intravenous (IV) fluid, IV antibiotics, IV antiemetics, and post-surgical monitoring. The patient was clinically stable following surgery as supported by the corresponding medical records.
Inpatient care may be indicated when there is right upper quadrant pain, and systemic signs of inflammation (fever, C-reactive protein greater than (>) 10, white blood cell count (WBC) count > 10 thousand (K)), acute cholangitis, common bile duct obstruction, vomiting that is severe or persistent, dehydration that is severe or persistent, hemodynamic instability, severe pain requiring acute inpatient management, signs of intestinal obstruction, bacteremia, need for percutaneous or open procedures, or other condition that requires inpatient admission.
While this patient did have abdominal pain and an elevated WBC count, the documentation in this case does not support that criteria were satisfied to justify an inpatient level of care as the patient was hemodynamically stable at presentation, underwent a cholecystectomy without complication and was able to be safely and appropriately discharged within 2 days.
There is no documentation of hemodynamic, pulmonary, neurological, or metabolic reason for an acute inpatient level of care. Additionally, there is no documentation of failure to achieve discharge criteria, conversion to open surgery, care for comorbidities, procedural complications, or any other condition requiring inpatient admission. The patient had an uncomplicated post-surgical recovery. He was able to be discharged from the hospital on the first post-surgical day.