This is a patient who presented to the emergency department (ED) with abdominal pain of new onset. She was known to have gallstones from a prior ultrasound examination. She had undergone an abdominoplasty several weeks prior. At the time of presentation, the patient was without a fever and vital signs were normal. She was tender in the right upper abdomen. The white blood cell count (WBC) was elevated at 12 thousand (K). The complete metabolic panel was normal. An ultrasound showed gallstones and gallbladder wall thickening consistent with acute cholecystitis. She was initially treated with intravenous (IV) fluid and IV antibiotics. She underwent a laparoscopic cholecystectomy. The operative dictation and the anesthetic record describe an uncomplicated cholecystectomy with Jackson-Pratt (JP) drain placement.

The patient was treated with post-surgical monitoring, IV fluid, IV analgesia, and antiemetics. The immediate post-surgical recovery was uncomplicated. On post-operative day number (#) 1 following surgery, the patient had stable vital signs. Her pain was controlled. Her diet was advanced. The patient remained clinically stable. The drain was removed and she was discharged from the inpatient setting.

The health plan's determination is overturned. Based on the submitted clinical documentation, an inpatient level of care was medically necessary. This patient was admitted to the hospital with the diagnosis of acute cholelithiasis/cholecystitis. Her white blood cell count (WBC) was elevated and an ultrasound which identified acute cholecystitis and gallstones. She underwent a laparoscopic cholecystectomy procedure. She required placement of a surgical drain at the time of surgery due to the degree of inflammation.

Inpatient stay may be needed for failure to achieve discharge status criteria, conversion to open surgery, systemic infection, care for active comorbidities, complications of procedure or for the diagnosis of acute cholecystitis. In this case, the records support the diagnosis of acute cholecystitis and warrant an inpatient level of care. Inpatient care is indicated when there is right upper quadrant pain, and systemic signs of inflammation (fever, C-reactive protein greater than (>) 10, WBC count > 10 K). Inpatient admission is also indicated for acute cholangitis, common bile duct obstruction, vomiting that is severe or persistent, dehydration that is severe or persistent, hemodynamic instability, severe pain requiring acute inpatient management, signs of intestinal obstruction, bacteremia, need for percutaneous or open procedures, or other condition that requires inpatient admission.

In this case, the patient presented with upper abdominal pain, an elevated WBC count (12K), and imaging findings that supported the diagnosis of acute cholecystitis. She required urgent operative treatment for this condition. These clinical findings justify an inpatient level of care. Inpatient level of care was consistent with generally recognized standards of care.