Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cholecystitis. 
Treatment: Inpatient hospital stay. 

The insurer denied coverage for inpatient hospital stay. 

The denial is upheld. 

This is an adult with a medical history of asthma, morbid obesity (Body Mass Index 43.7), gallstones, and obstructive sleep apnea. The patient presented to the hospital with right upper quadrant pain, nausea, vomiting, and mild leukocytosis. Ultrasound of the abdomen showed hepatomegaly and cholelithiasis with sonographic evidence of acute cholecystitis. The patient underwent a laparoscopic cholecystectomy. 

The literature confirms that the safety and efficacy of outpatient laparoscopic cholecystectomy (LC) has been well established. As Lillemoe et al (1999) have noted, laparoscopic cholecystectomy has achieved universal acceptance as the "gold standard" for the treatment of cholelithiasis and cholecystitis. Many centers have utilized "short stay" units for post-operative observation following a laparoscopic cholecystectomy. These authors retrospectively analyzed 130 consecutive patients undergoing LC in an outpatient surgery unit. There were no conversions to an open procedure. Eight patients (6.2%) were admitted to the hospital directly from the post anesthesia care unit (PACU), and 6 of these patients were discharged to home on post-operative day 1. An additional 6 patients (4.6%) required hospital admission following discharge from the PACU, and 3 of these 6 patients were also discharged on post-operative day 1. These authors concluded that laparoscopic cholecystectomy can safely and effectively be performed "as a true outpatient procedure with patients being discharged to home within hours of completion of the procedure." Less than 10% of patients will require hospital admission, and less than 5% of patients may require hospitalization following discharge to home. 

Tenconi et al (2008) reviewed the indications and safety of laparoscopic cholecystectomy (LC) as a day-surgery procedure. These authors reviewed a total of 20 randomized clinical trials from 2000-2008 that examined laparoscopic cholecystectomy in patients with symptomatic chronic cholelithiasis. Their extensive review concluded that day-surgery LC is safe and feasible in selected patients. Serious complications are rare, and most frequently prolonged hospital stay and readmission are related to minor, more easily controlled complications or for social reasons. The success of day surgery laparoscopic cholecystectomy depends on appropriate patient selection, well trained staff, and safe anesthesia. Adequate control of pain, nausea, or vomiting is an essential component of successful day surgery laparoscopic cholecystectomy. 

Ripetti et al (2019) examined the predictive factors aimed at facilitating cholecystectomy in a day surgery setting. These authors retrospectively examined 985 consecutive patients who underwent elective laparoscopic cholecystectomy for gallstone disease between May 2006 and February 2015. These patients were divided into two groups: group A with a length of stay less then or equal to 2 days (922 patients) and group B with a length of stay greater then 2 days (63 patients). These authors concluded that prolonged length of stay following laparoscopic cholecystectomy is related to the patient's comorbid medical conditions.

There is no documentation that the patient had any complications or conditions that would require inpatient admission. There is no documentation of perioperative or postoperative complications, co-morbid conditions, or hemodynamic instability that would require management in the acute setting. Therefore, the medical necessity for the inpatient admission has not been established. The care that was received could have been performed safely and effectively on an outpatient basis. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for inpatient hospital stay is not substantiated.