Diagnosis: Cholecystitis

Treatment: Inpatient Admission

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

This is a female patient who presented to the emergency department with complaints of abdominal pain and vomiting. She had an ultrasound of her abdomen that revealed a 1cm gallstone at the gallbladder neck. The patient's vital signs revealed a temperature of 97.4 degrees with a heart of 66 bpm. Blood pressure was 140/77 and oxygen saturation was 100%. The physical exam revealed tenderness to the left upper quadrant and right upper quadrant. It was recommended the patient undergo laboratory and diagnostic studies. The patient's laboratory studies did not reveal any significant abnormalities. The patient did undergo an ultrasound of the right upper quadrant revealing a 1 cm gallstone at the gallbladder neck. There was no sonographic evidence of cholecystitis. A CT scan of the abdomen and pelvis revealed moderate constipation. The patient was treated with intravenous (IV) fluids, IV Morphine for pain and anti-emetic for nausea. Her symptoms resolved and she was discharged with follow up instructions for treatment.

According to current literature inpatient care is appropriate for a patient when there is evidence of acute cholecystitis as indicated by right upper quadrant pain, systemic signs of inflammation such as a white blood cell count greater than 10,000, C-reactive protein level greater than 10 mg/liter or fever. Additionally, if the patient has common bile duct obstruction diagnosed by imaging, severe persistent vomiting, severe persistent dehydration, hemodynamic instability or severe pain requiring acute inpatient management patient may be admitted. The submitted documentation revealed the patient had a 1 cm gallstone at the gallbladder neck however there was no sonographic evidence of cholecystitis. While the documentation detailed the patient did have additional episodes of nausea and vomiting while in the Emergency Department the guidelines indicate there must be numerous episodes of vomiting occurring in 24 hours such as every 1-2 hours that is not controlled with appropriate anti-medic treatment to include repeated oral or parenteral dosing.

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