Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Cholecystitis in pregnancy. 
Treatment: Full hospital admission. 

The insurer denied coverage for the full hospital admission. 

The denial is modified. 

This is a female patient with a past medical history of cholelithiasis who presented to the Emergency Department (ED) at 20 weeks gestation, with a chief complaint of severe abdominal pain and nausea. The patient's severe abdominal pain was attributed to her known history of gallstones. She was seen for similar symptoms approximately 9 weeks prior but denied surgery at the time. In the ED, the patient's vital signs were stable. Obstetrics was consulted and the patient received intravenous (IV) pain medication. The patient was admitted as an inpatient for pain control, IV fluids, and bowel rest. Her pain improved and she was started on simple clear liquids which she tolerated without increased pain. The patient was discharged, and she was instructed to continue just liquids, toast, and crackers for 36 hours and only then advance to strict low fat food if she is then pain free. The patient was also instructed that if her pain worsens again as her diet advances, she should return to the ED to be reevaluated for possible laparoscopic gallbladder surgery during her second trimester. 

The patient was pregnant and was diagnosed with cholecystitis. Cholecystitis should be considered in the evaluation of any pregnant woman with abdominal complaints. Acute cholecystitis can mimic many other intra-abdominal problems, both obstetric and non-obstetric. Most patients respond to conservative management, with minimal increase in maternal or fetal morbidity and mortality. A few will not respond to therapy or will have severe complications requiring more aggressive management, including surgery. 

The initial management of pregnant patients with gallstone disease is supportive and includes pain control, IV fluid therapy, and, for patients with acute cholecystitis, antibiotic therapy. Additional imaging and repeat laboratory studies are indicated to assess for potential complications if symptoms worsen. For pregnant patients who develop acute cholecystitis during the first two trimesters, a cholecystectomy is recommended rather than conservative therapy alone or interval cholecystectomy. Prompt surgical intervention decreases relapse rates and hospital readmissions. 

This patient was pregnant and was diagnosed with cholecystitis. Admission for IV fluid and pain management and close monitoring for worsening condition that could put the patient and the fetus at risk was medically necessary. However, on day 2 of admission, the patient improved and could have been discharged home that day. 

Continuous admission from day 2 of admission to day 3 of admission was not medically necessary. 

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

The hospital admission on day 1 of admission is considered medically necessary for this patient. Continuous admission from day 2 of admission to day 3 of admission was not medically necessary. 

The insurer's denial of coverage for the full hospital admission is modified.