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 right upper quadrant (RUQ) abdominal pain. The patient presented to the Emergency Department (ED) with RUQ abdominal pain. The patient was afebrile. The patient has a history of gastritis, gallstones, and fibroids and presented for evaluation of RUQ pain. The pain was associated with one episode of vomiting. On exam the patient had a soft non distended abdomen without rebound or guarding. The abdomen was tender to palpation in the RUQ. The white blood cell (WBC) count was 7.2 with alkaline phosphate of 75, Aspartate aminotransferase (AST) 14, Alanine transaminase (ALT) of 18 and total bilirubin of 0.5. The abdominal ultrasound revealed cholelithiasis with a stone at the neck with mild gallbladder wall thickening. The sonographic Murphy sign could not be evaluated in the patient receiving pain medication. The common bile duct was 8 millimeters (mm). The findings were suggestive of acute cholecystitis. 

The patient had a hepatobiliary iminodiacetic acid (HIDA) scan and revealed findings consistent with cystic duct obstruction or a nonfunctioning gall bladder. The progress note indicated the patient had no acute events overnight. The patient endorsed minimal RUQ pain. There was no nausea or emesis. The abdomen was soft, non-tender, and non-distended. The plan was for a laparoscopic (lap) cholecystectomy. The patient was taken to the operating room and underwent an uneventful lap cholecystectomy. The findings were thickened edematous gallbladder. Pathology revealed chronic cholecystitis with cholelithiasis. The progress note indicated the patient had no acute events overnight. The pain was minimal. The patient vomited after a clear liquid diet. The plan was to discharge pending tolerating a regular diet. 
Based upon the records the reviewer does feel that the acute inpatient admission was not justified as this patient could have been managed as noted by the insurer in an ambulatory/observation setting as the patient had an uneventful lap cholecystectomy for cholelithiasis. The patient did not have a significantly elevated WBC count 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. But this could have been done in an ambulatory/observation setting. 

According to MCG (Milliman Care Guidelines) Inpatient and Surgical Care 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% of the laparoscopic cholecystectomies were performed either the day of presentation (day 0) or the following day (day 1)."  Thus, ambulatory status would have been appropriate as the patient should have had the procedure done on day 0 or day 1 and then discharged.

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 admission is not substantiated.