Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gallstones	
Treatment: Surgery

The insurer denied inpatient admission. The denial is upheld.

This is the case of a female patient who presented to the emergency department (ED). As per the history and physical, the patient has a past medical history of depression and thyroid nodule and presented with symptomatic cholelithiasis. She had a prior history of gallstones and gastric sleeve. As per the ED provider note, the patient was diagnosed with gallstones six months prior to this admission. She has worsening right upper quadrant pain (RUQ) pain after eating yogurt. She had a gastric sleeve six months prior to this admission. She was afebrile with stable vital signs (Blood Pressure 153/111). An abdominal exam revealed tenderness, with the abdomen being soft. White blood count (WBC) was 11.9. Lipase was 453. Liver function tests (LFT) were normal. The plan was no oral intake (NPO), and when the pain was resolved they would do a cholecystectomy.

Bariatric surgery saw the patient and noted the history. The exam revealed a positive Murphy sign. Computed Tomography (CT) of the abdomen revealed irregular wall thickening versus trace pericholecystic fluid. There was an area of hypo attenuation, most likely representing focal fatty deposition. The patient was admitted to surgery and consented but was not booked for a laparoscopic (lap) cholecystectomy.

A sonogram revealed a gallbladder with multiple stone notes. Pericholecystic fluid was absent, as well as gallbladder wall edema. The common bile duct (CBD) was normal in size.

The patient was taken to surgery and underwent a robotic cholecystectomy for symptomatic cholelithiasis. The surgery was uneventful. Surgery started at 05:13 and was completed by 06:30. Pathology reporting revealed chronic cholecystitis with cholelithiasis.

Postoperatively, the patient did well and was discharged.

Based upon the records and the Milliman Care Guidelines cited below, 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 for biliary colic. She did not have a significantly elevated WBC, and she did not have a fever. She did not have abnormal liver function tests. This patient had biliary colic and a history of such and needed her gallbladder taken out. She did have an elevated lipase but without amylase documented. The patient presented to the hospital and was not taken to the operating room until the second day of admission. The patient was discharged later that day after surgery. The procedure could have been done in an ambulatory/observation setting. 

This patient did not need to be admitted. She did not have any indication for an acute inpatient admission. She did not have acute cholangitis or acute cholecystitis, but, as noted in the progress note, she had biliary colic. Her WBC was not significantly abnormal, and her LFTs were normal. She had no fever.  

Furthermore, MCG Health in General recovery care 27th edition General admission criteria GRG: CG-GAC (ISC GRG) note that admission is indicated for 1 or more of the following: Hemodynamic instability; Acute cardiac or peripheral ischemia; Cardiac arrhythmias of immediate concern;  Severe respiratory findings; Severe airflow or ventilation abnormalities, Anasarca; Neurologic abnormalities;  Altered mental status that is severe or persistent, Physiologic disorder (e.g., acute acidosis, thyroid storm, adrenal crisis) that is severe or persists despite observation care,  Suspicion for or diagnosis of abdominal catastrophe, Temperature less than 95 degrees Fahrenheit  (F) (35 degrees Celsius (C)) (rectal),  Severe electrolyte abnormalities requiring inpatient care;  Severe anemia; High-risk low platelet count; Disseminated intravascular coagulation; adverse drug or systemic toxin reaction that is severe or persists despite observation; Severe pain requiring acute inpatient management; Inpatient monitoring needed; Treatment requiring inpatient care; Emergency procedures needed. Based on these guidelines, this patient should have been observed rather than placed in an acute admission, as she did not have any indication, as noted above, for an inpatient stay or prolonged stay. She did not need acute inpatient admission but rather observation status. She presented to the ED late in the evening and was not taken to the operating room until the second day of admission, and she was discharged later that day. All of this could have been done in a 23-hour observation setting, as lap cholecystectomy for biliary colic is an outpatient ambulatory procedure.

Based on the above, the insurer's denial must be upheld. The health care plan acted reasonably, with sound medical judgment, and in the patient's best interest. The medical necessity for inpatient admission is not substantiated.