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 an adult patient with a history of gallstones. As per the triage note the patient presented complaining of right upper quadrant (RUQ) abdominal pain associated with nausea and vomiting. The patient denied fever or chills. The patient was afebrile with stable vital signs. As per the Emergency Department provider note, the patient complained of abdominal pain and vomiting for 3 hours. The pain was worse after eating. The patient stated that the pain was from her gallbladder and wants to have it removed. On exam the abdomen was soft and tender with RUQ pain and positive Murphy sign. Empiric antibiotics were ordered, and the surgery consult was placed. The assessment was acute cholecystitis.

The History and Physical by surgery noted that the patient presented with pain and subjective fevers, nausea, and vomiting. The patient had similar episodes in the past. Of note the patient was recently post-partum and had a recent admission for gallstone pancreatitis. Labs included a white blood cell (WBC) count of 12.62, Aspartate aminotransferase (AST) of 62, and a Alkaline Phosphate (ALP) of 146. The abdomen was soft with tenderness to palpation in the RUQ and with negative Murphy sign. The patient underwent an uneventful laparoscopic (lap) cholecystectomy with findings of acute cholecystitis. Post operatively the patient did well and was discharged home.

Based upon the records, the acute inpatient admission was not justified as this patient could have been managed in an ambulatory or observation setting as the patient had an uneventful lap cholecystectomy for cholelithiasis. The patient did not have a significantly elevated WBC and the patient did not have a fever. The patient did not have markedly abnormal liver function tests. The patient did merit having the gallbladder taken out as the patient presented to the hospital asking to have it taken out because of increasing episodes of pain. This could have been done in an ambulatory or observation setting. 

According to MCG (Milliman Care Guidelines) Inpatient and Surgical Care (ISC) 26th Edition cholecystectomy by laparoscopy the operative status criteria is ambulatory. This patient should have been managed without an inpatient acute admission for this procedure. MCG also noted "that analysis of a cohort of 95,523 adult patients who underwent laparoscopic cholecystectomy within 10 days of presentation with acute cholecystitis found that 65% (percent) of the laparoscopic cholecystectomies were performed either the day of presentation (day 0) or the following day (day 1)." Ambulatory status would have been appropriate.

MCG General recovery care 26th edition Ambulatory surgery exception criteria General Recovery Guidelines (GRG):CG-AEC 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 a finding that warrants inpatient stay. 

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 an inpatient admission is not substantiated.