Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic Calculous Cholecystitis. 
Treatment: Inpatient Admission. 

The insurer denied coverage for inpatient admission. 

The denial is upheld. 

This is the case of an adult female with no past medical history who presented to the Emergency Department (ED) with complaints of flank pain. As per the ED provider note the patient presented with bilateral flank pain, sharp, radiating around to the right side of the abdomen in the right upper quadrant (RUQ). This started the night before. She denied nausea, vomiting, fever, or chills. Exam revealed the patient to be afebrile with stable vital signs with RUQ tenderness without guarding or Murphy sign. The assessment was possible hepatobiliary pathology, and the plan was bedside sonogram and labs. The white blood cell (WBC) count was 10.1. Total bilirubin was 1.4 with alanine transaminase (ALT) of 685 and lipase of 122 and aspartate aminotransferase (AST) of 1092. The patient was admitted to surgery for urgent gallbladder surgical intervention. 

The assessment was work up for significant for gallstone burden in the gallbladder with transaminitis. This represents biliary colic but due to the transaminitis and elevated direct bilirubin choledocholithiasis must be ruled out. The plan was to obtain an official abdominal ultrasound and magnetic resonance cholangiopancreatography (MRCP) in the morning. The plan was for tentative lap cholecystectomy if workup for choledocholithiasis is negative. 

The patient was unable to have MRCP due to a burning itching sensation during the magnetic resonance imaging (MRI). Abdominal sonogram showed gallbladder contracted with no wall thickening and shadowing consistent with calculi. There was no biliary dilation. Progress note indicated the patient was afebrile and continues to report RUQ pain. The patient denied fever or chills. On exam there was no rebound or guarding and mild RUQ pain. The plan was lap cholecystectomy tomorrow. 

The patient underwent a lap cholecystectomy with intraoperative cholangiogram (IOC) with the findings of chronic calculous cholecystitis. IOC did not show any filling defects in the common bile duct (CBD) to indicate any stones at this time. The patient did well and was discharged for follow up. 

According to the guidelines of MCG Health Inpatient and Surgical care- 25th edition Gallbladder or bile duct inflammation or stone the goal length of stay is ambulatory or 2 days and assumes optimal recovery, decision making, and care. Patients may be discharged to a lower level of care (either later than or sooner than the goal) when it is appropriate for their clinical status and care needs. The clinical indications for admission to inpatient care may include patients with 1 or more of the following: Acute cholangitis as indicated by ALL of the following: Systemic signs of inflammation indicated by 1 or more of the following: Fever, C-reactive protein level greater than 10 mg/L (gram per liter), ...

This patient did not have signs and symptoms for acute cholecystitis as she did not have elevated WBC, fever, or confirmatory test to show acute cholecystitis. She did have RUQ tenderness and elevated liver enzymes however, there was no evidence of choledocholithiasis as the sonogram did not show biliary dilation. It did only show a contracted gallbladder and did not show evidence of acute cholecystitis. She did have an uneventful lap cholecystectomy and IOC and was discharged - all of which could have been done in an observation/ambulatory setting as she could have had a speedier workup and had the lap cholecystectomy and discharged on that day. It should not have taken two more days until discharge. 

The health plan acted reasonably with sound medical judgment in the best interest of the patient as the patient did not meet criteria for admission but rather ambulatory/observation status. 

The insurer's denial of coverage for the inpatient admission is upheld. Medical necessity is not substantiated.