Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute Cholecystitis
Treatment inpatient admission
The insurer denied coverage for inpatient admission
The denial is upheld.

This is the case of a patient with a past medical history of asthma who presented to the emergency department (ED) with complaints of RLQ (right lower quadrant) abdominal pain and shoulder pain. She denied trauma, fall, fever or chills. On exam, she had tenderness in the RUQ (right upper quadrant). She was afebrile with stable vital signs. The plan was labs, abdominal sonogram and reassess. White blood cell count (WBC) was 10. Labs included AST (aspartate aminotransferase)12, ALT (alanine transaminase) <10, ALP (alkaline phosphatase) of 73 and total bilirubin of 0.5.

Sonogram was done and showed multiple gallstones with no sonographic evidence for acute cholecystitis. She was seen by surgery and admitted to surgery. Computed tomography (CT) showed no internal external hepatic biliary duct dilation. No gallstones were identified, and the gallbladder was not distended. Progress notes by surgery indicated the patient was afebrile with RUQ pain and the plan was to hydrate, pain control and HIDA (hepatobiliary iminodiacetic acid) scan. HIDA scan revealed no scintigraphic evidence of biliary obstruction with patent common and cystic ducts.
Progress notes indicated the pain was much better and that she was hungry. The plan was lap (laparoscopic) cholecystectomy and the patient has severe biliary colic. Progress notes indicated the patient was stable and the plan was for lap cholecystectomy the next day. The attending noted that the patient was to have the lap cholecystectomy earlier but due to the busy OR (operating room) schedule there was going to be a delay. After speaking to the patient, the decision was made to send the patient home. The patient's clinical exam was stable, and she was feeling much better. Her abdomen pain was improved.  The hospital noted that her symptoms may have worsened to the point of gallbladder perforation, sepsis, and death if the patient had been discharged with continued symptoms.

Based upon the records provided, the inpatient admission was not justified as this patient should have been managed as noted by the insurer in an ambulatory/observation setting. The patient did not have acute cholecystitis as there was no radiologic finding to support this. At best, this patient had biliary colic and did not require inpatient hospitalization for this. Thus, she did not need the inpatient admission but rather observation. It should be noted as that well that her ALT and AST were normal as well as the bilirubin and ALP. Her WBC was only 10 thus there were no findings to support acute cholecystitis in this patient.

In addition, MCG (Milliman Care Guidelines) General recovery care 26th edition Ambulatory surgery exception criteria notes that potentially ambulatory procedure or surgery warrants inpatient care due to 1 or more of the following: Inpatient care needed for 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, the patient did not warrant inpatient status as there was no concern for a clinically significant preop disease and in the end, she did not require any surgical procedure acutely. Thus, inpatient admission was not warranted.
The inpatient admission was not justified at the inpatient admission level as the patient should have been managed in an ambulatory/observation setting. 

The health care plan acted reasonably with sound medical judgment and in the best interest of the patient.  

The medical necessity for inpatient admission is not substantiated.