Diagnosis: Cholelithiasis

Treatment: Inpatient admission, surgery, monitoring, medication

The insurer denied the inpatient admission. The denial was upheld.

The patient was a female who presented to the Emergency Department (ED). The patient had a past medical history of anxiety, depression, morbid obesity, and a sleeve gastrectomy. The patient had subjective complaints of worsening, intermittent epigastric pain x2 days. The patient had associated symptoms of nausea, vomiting and chills. The pain was rated 9-10/10 scale. The patient's blood pressure was 107/69. The patient underwent an ultrasound which revealed cholelithiasis. The patient was admitted and treated with intravenous antibiotics. She underwent a laparoscopic cholecystectomy. The findings revealed extensive gastric adhesions which required lysis. The patient tolerated the surgical procedure. No complications were noted. The patient was treated with pain management post-operatively. The patient was stabilized and discharged.

The Milliman Care Guidelines indicate that a cholecystectomy is generally performed on an ambulatory basis. An inpatient stay may be appropriate for patients who have a failure to achieve discharge status criteria or those who have active comorbidities. The guidelines also indicate that an exception for ambulatory surgery would include patients in need of an emergent procedure. The records indicated that the patient had a history of anxiety, depression, morbid obesity and a sleeve gastrectomy. The patient was not noted to need an emergent procedure as she did not go from the emergency room straight to the operating room. The records failed to support that the patient could not have been observed instead of being acutely admitted prior to the procedure.

The carrier's denial of coverage for the inpatient admission is upheld. The medical necessity is not substantiated.