Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cholecystitis.

Treatment: Inpatient admission.

The insurer denied the inpatient admission.

The denial was overturned.

This is a female patient with a history of thyroid disease and adrenal insufficiency who presented to the Emergency Department (ED) with complaints of abdominal pain, vomiting and diarrhea for one week.  The patient reported that she was recently seen in the ED for gastroenteritis and that her symptoms had not improved.  The patient was taking famotidine and Zofran without relief.  On exam the patient was ill appearing with the abdomen soft, non-distended, tender to touch without rebound or guarding.  Surgery was consulted and recommended that the patient be taken to the Operating Room (OR) in the morning. The patient's white blood cell (WBC) count was 7.98 with normal liver function tests (LFT's).  The patient's ultrasound of the abdomen revealed gallbladder wall thickening, cholelithiasis, with pericholecystic fluid and positive ultrasonographic Murphy's sign highly suspicious for acute cholecystitis. The patient was made nothing by mouth (NPO) and intravenous (IV) fluids and IV Zosyn were administered. Endocrinology was consulted and noted this patient's history of adrenal insufficiency and recommendation were made to continue prednisone and levothyroxine. The patient's abdomen was soft, mildly distended with mild tenderness to palpation.  The patient continued to be afebrile. The patient continued on clear liquids. Further imaging was reviewed and the physician decided not to operate due to extensive inflammation and gross gallbladder wall thickening; an outpatient cholecystectomy was planned. The patient clinically improved and was cleared for discharge to home.

According to the MCG Health Inpatient and Surgical care- 24tth edition Gall Bladder or Bile Duct Inflammation or Stone ORG: M-555 (ISC) clinical indications for admission to inpatient care may include patients with: (1) Acute cholecystitis as indicated by ALL of the following: Right upper quadrant pain, mass, or tenderness; Systemic signs of inflammation indicated by 1 or more of the following: Fever, C-reactive protein level greater than 10 mg/L, White blood cell count greater than 10,000/mm3 (10 x109/L) or less than 4000/mm3 (4 x109/L); and/or (2) Cholecystectomy not anticipated (i.e., within subsequent few days) due to 1 or more of the following: High surgical risk (e.g., severe comorbidities, organ failure), Interval cholecystectomy planned (i.e., not during current hospitalization).

The patient presented with clinical signs and symptoms for acute cholecystitis.  The surgeon initially was going to perform the cholecystectomy during this admission but then decided that it would be safer to wait until the inflammation subsided given the thickness of this patient's gall bladder wall and inflammation that were present.  Therefore, in this case the patient did require an inpatient setting and hospital services as the patient could not have been cared for in an ambulatory/observation setting. Thus, inpatient admission was medically necessary in order to properly treat this patient's acute cholecystitis complicated by an extensive inflammation with intravenous antibiotic and monitoring.

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the hospital admission should be overturned.  The medical necessity is substantiated.