Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cholelithiasis/cholecystitis
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a man. He presented for a scheduled cholecystectomy. His comorbid health conditions included hypertension, history of coronary artery disease, aortic stenosis, ascending aortic aneurysm, hiatal hernia, and prior acute cholecystitis treated with percutaneous cholecystostomy.

At the time of presentation, the patient was without fever, and vital signs showed a normal heart rate and blood pressure of 166/77 mmHg (millimeters of mercury). He was treated with laparoscopic cholecystectomy, lysis of adhesions, removal of the existing cholecystostomy tube and placement of a surgical drain. The operative dictation describes a difficult procedure due to scarring, adhesions, and inflammation during which the cystic duct avulsed from the common bile duct requiring suture repair of the common duct.

The patient was treated with post-surgical monitoring, IV (intravenous) fluid, IV (intravenous) analgesia, and antiemetics. The immediate post-surgical recovery was uncomplicated. Day two, following surgery, the patient had stable vital signs. The patient did complain of bloating and gas pain. The diet was advanced. The JP (Jackson Pratt) drain had 25-cc (cubic centimeters) of serosanguinous fluid output on day three. The patient remained clinically stable and was discharged from the inpatient setting on day three.

The health plan letter references MCG (Milliman care guidelines) 24th ed. Cholecystectomy by laparoscopy. The health plan letter states that hospital admission was not medically necessary. That determination is being appealed.

No, the Inpatient admission was not medically necessary.
This patient is a man who presented to the hospital with known cholelithiasis/cholecystitis for a scheduled cholecystectomy procedure. There is no documentation of hemodynamic, pulmonary, neurological, or metabolic reason for an acute inpatient level of care at the time of presentation. 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. While the procedure was difficult due to scarring, adhesions, and inflammation, the procedure was successfully completed laparoscopically, and the ductal injury was identified and repaired.

Acute inpatient care was not medically necessary for this patient as the care and treatment provided could have been rendered at a lower level of care. A lower level of care would have provided for surgical assessment, operative treatment, perioperative care and monitoring, provision of IV (intravenous) fluid and medication, and overnight care. The patient was admitted to the hospital and was stable for discharge from the hospital within 48-hours. The care provided during this time could have reasonably been rendered at a lower level of care.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
There is no compelling reason documented as to why this patient could not have safely and appropriately been treated at a lower level of care. Based on the submitted clinical documentation, an inpatient level of care was not medically necessary. This patient was admitted to the hospital with the diagnosis of cholelithiasis/cholecystitis. The patient underwent a difficult laparoscopic cholecystectomy procedure and repair of ductal injury. His post-surgical monitoring did not identify a surgical complication, and the surgical drain put out only 25-cc (cubic centimeters) of serosanguinous fluid. He remained stable and was discharged from the hospital.

Inpatient level of care was not medically necessary. A lower level of care would have permitted for the pre-surgical assessment, the surgical procedure and perioperative IV (intravenous) fluid, IV (intravenous) antibiotics, IV (intravenous) antiemetics, and post-surgical monitoring. The patient was clinically stable following surgery as supported by the corresponding medical records.

Inpatient stay may be needed for failure to achieve discharge status criteria, conversion to open surgery, systemic infection, care for active comorbidities, or complications of procedure. A lower level of care would have satisfied the clinical needs of this patient.

The health plan referenced MCG (Milliman care guidelines)- Cholecystectomy by laparoscopy, Inpatient and Surgical Care 24th edition. These MCG (Milliman care guidelines) state that inpatient care is indicated when there is right upper quadrant pain, and systemic signs of inflammation (fever, C-reactive protein > (greater than) 10, WBC [white blood cell] count > (greater than) 10 K [thousand]). Inpatient admission is also indicated for 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. In this case, none of these indications existed to justify an inpatient level of care.