Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cholecystitis.
Treatment: Inpatient admission.

The insurer denied coverage for an inpatient admission.  The denial is upheld.

This is the case of a female with a history of a C (cesarean) section, and obesity s/p (status post) gastric sleeve surgery, who presented to the ED (emergency department) with complaints of nausea, vomiting and RUQ (right upper quadrant) pain. The patient was recently admitted to an outside hospital for cholecystitis. She declined surgery there. The patient presented to the ED as per the H (history) and P (physical) of the ED provider, for further management of cholecystitis. On exam she was alert and in no acute distress. The abdomen was soft with RUQ and epigastric tenderness to palpation. There was no rebound or guarding. She was afebrile. She had been on antibiotics for five days. The plan was labs, imaging, pain control and a surgical consult. The patient was admitted. A sonogram showed multiple gallstones with positive Murphy's sign.

MCG (Milliman Care Guidelines) Inpatient and Surgical Care 26th edition Cholecystectomy with common duct exploration by laparoscopy ORG: S-371 (ISC) notes that the procedure is indicated for 1 or more of the following: Common bile duct stone or obstruction suspected or confirmed, as indicated by 1 or more of the following: Pancreatitis suspected to be due to common bile duct stone or obstruction; Preoperative or intraoperative procedure or imaging (e.g., ultrasound, ERCP (endoscopic retrograde cholangiopancreatogram), cholangiogram, CT (computed tomography) scan, MRI (magnetic resonance imaging) consistent with common bile duct stone or obstruction. The patient underwent a common duct exploration via the cystic duct remnant because of a filling defect on the intraoperative cholangiogram. There was no stone found in the duct. Furthermore the operative status criteria is Ambulatory: nonelderly patients (younger than 65 years) with limited gallbladder, hepatic, or pancreatic inflammation, and without comorbid disease that requires prolonged (more than 24 hours) postoperative monitoring; Inpatient: most elderly patients (age 65 years or older); patients with acute cholecystitis, pancreatitis, suspected cholangitis, or hepatitis; and patients with significant comorbid disease requiring prolonged (more than 24 hours) postoperative monitoring. This patient as noted could have been done in ambulatory setting as she did not have any comorbid conditions and only required observation as noted by the insurer. Given the above the patient did not warrant inpatient status, but ambulatory for this procedure. She did not warrant inpatient care, as she did not have a significant preoperative disease or condition.

Finally, MCG General Recovery Care 26th edition Ambulatory surgery exception criteria GRG:CG-AEC (ISC GRG) notes that a potentially ambulatory procedure or surgery warrants inpatient care due to 1 or more of the following: Inpatient care needed for a 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 information the patient did not warrant inpatient care.

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 is upheld. Medical Necessity is not substantiated.