Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cholecystectomy
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is overturned
 
This is the case of a young adult with a history of gallstones. As per the triage note the patient presented complaining of a gallbladder attack. She has had these attacks in the past. Her vital signs were stable, and she was afebrile. She stated she was pregnant. She complained of nausea and vomiting for 3 days. She was told to go to the Emergency Department (ED) if the pain was not better. ED provider note indicated she presented with right upper quadrant (RUQ) pain. She was diagnosed with cholelithiasis 7 years ago. She has worsening pain with decreased appetite. On exam her abdomen was tender in the RUQ. She was made nothing by mouth (NPO) and given intravenous (IV) fluids. Her White blood cell (WBC) count was 8.9. Her quantitative human chorionic gonadotropin (B-HCG) was positive. Ultrasound of the abdomen revealed cholelithiasis with borderline gallbladder wall thickening Her liver function tests (LFT's) were normal with a bilirubin of 1.6.

Surgery consult indicated the patient had RUQ pain without fever or chills. She has had persistent RUQ pain with nausea and vomiting daily. Surgery did elicit a positive Murphy's sign. The assessment was patient with cholelithiasis and approximately 19 weeks pregnant. The plan was to admit to surgery and obtain magnetic resonance cholangiopancreatography (MRCP) and obstetric/gynecological (OB/GYN) evaluation.

OB/GYN saw the patient and noted the history of RUQ pain with history of gallstones. Ultrasound revealed a single live intrauterine pregnancy measuring 15.6 weeks. The recommendations were that the patient should be admitted to general surgery and if proceeding with surgical management OB recommended fetal heart rate check pre and post op; left lateral decubitus positioning intra operatively; use of Palmer's point for laparoscopic entry and establish prenatal care soon following discharge.

The patient was taken to the operating room for laparoscopic cholecystectomy. Findings at the time of surgery included acute gangrenous cholecystitis. A Blake drain was placed. Path revealed gallbladder with ulceration, with acute necrotizing cholecystitis, abscess formation and granulation tissue.

Based upon the records acute inpatient admission was justified as this patient had acute cholecystitis and was also pregnant. The pregnancy increased the risk for this patient, and she therefore needed to be monitored as an inpatient once the decision was made to proceed with surgery. In fact, the gall bladder was found to be gangrenous with area of abscess on pathology. This patient could not have this surgery done in the ambulatory setting given her pregnancy and the recommendations of the OB team that she needed fetal monitoring. In addition, the surgical team wanted an MRCP to assess the common bile duct given the bilirubin of 1.6. Thus, in this case acute inpatient admission was warranted. This patient did need to be admitted as she could not have been managed with an outpatient/observation basis given the pregnancy and the need for monitoring. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for an inpatient admission is substantiated.