Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cholecystitis
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a male patient who presented to the hospital with a complaint of abdominal pain. Comorbid health conditions included thyroid cancer for which he had undergone a thyroidectomy and there was a history of a prior distal gastrectomy for gastric cancer and prior hiatal hernia repair. The vital signs were normal at the time of presentation. He had tenderness in the right upper quadrant. An ultrasound showed gallstones in the gallbladder, a wall thickness of 4.7-millimeters (mm), a normal caliber common duct, consistent with acute calculus cholecystitis. A computed tomography (CT) scan showed a dilated gallbladder with stones and a common duct of 9-mm. He was started on intravenous (IV) antibiotics. The surgical history and physical (H&P) states that the patient had cholecystitis for which a laparoscopic cholecystectomy was scheduled and performed. The operative note describes an acutely inflamed and gangrenous gallbladder. A laparoscopic cholecystectomy was performed without complication.
The diet was advanced and the pain was controlled with oral medications. The patient's vital signs were normal. The patient remained clinically stable and was discharged from the inpatient setting.

At issue is the medical necessity of an inpatient stay. An inpatient stay was not medically necessary for this patient.

The patient presented to the hospital with a complaint of abdominal pain. Imaging and a surgical consultation were performed and established the diagnosis of cholelithiasis/cholecystitis. At the time of presentation and at the time of surgical assessment, the patient had normal vital signs and was without a fever. An ultrasound confirmed cholelithiasis/cholecystitis. Lab data identified an elevated white blood cell count (WBC) and serum transaminases. The perioperative and early post-surgical recovery were uncomplicated and the patient was stable for discharge from the hospital on the first post-surgical day. Acute inpatient care was not medically necessary for this patient as the care and the treatment provided could have been rendered with a lower level of care, which would have provided for initial assessment, perioperative care and monitoring, provision of intravenous (IV) fluid, surgical consultation, performance of a cholecystectomy, and overnight care. There were no peri-procedure complications or other clinical issues.

Inpatient care may be needed when there is:
-Acute cholangitis with systemic signs of sepsis and evidence of common bile duct disease with bilirubin greater than (>) than 2 milligrams per deciliter (mg/dl) or aspartate aminotransferase (AST)/ alanine aminotransferase (ALT) 1.5 times upper limit of normal, or imaging showing biliary dilatation or evidence of etiology
-Acute cholecystitis (right upper quadrant (RUQ) pain or tenderness, systemic signs of inflammation, Cholecystectomy not anticipated due to high surgical risk or plan for interval cholecystectomy)

Also, criteria for inpatient admission may include:
-Failure to achieve discharge criteria
-Conversion to open surgery
-Severe post-operative infection
-Care for active comorbidities
-Complications of procedure
-Gallstone ileus

The patient's presenting condition at the hospital, lab data and his clinical course did not justify an inpatient level of care. The care provided could have appropriately been rendered with a lower level of care.