Primary Diagnosis: Digestive System/GI
Secondary Diagnosis: Cholecystitis
Treatment: Inpatient hospital stay

This is a patient with a history of cholelithiasis, gastroparesis, and marijuana abuse, who presented to the emergency department (ED) on with complaints of a one-day history of nausea, vomiting, and epigastric pain. Vital signs were normal. Physical exam revealed right upper quadrant tenderness. Ultrasound showed cholelithiasis with a normal common bile duct and hepatosteatosis. The white blood cell (WBC) count was elevated to 14.2 with a left shift. Liver function tests were normal. The patient was admitted, started on antibiotics, and offered a laparoscopic cholecystectomy.
2 days later the patient underwent a laparoscopic cholecystectomy that was essentially uncomplicated, except for pulsatile bleeding from the liver bed that was quickly and easily controlled with clips.
The next day the patient met discharge criteria including normal vital signs, adequate pain control, tolerating a diet, and ambulating well. Patient was discharged to home and asked to follow-up in a week. The health plan's determination of medical necessity is upheld in whole. Although 24 hours of IV antibiotics did resolve this patient's leukocytosis, this patient was not "septic"; therefore, there was no medical benefit in delaying surgery for this. The literature does not support a medical benefit for delay to laparoscopic cholecystectomy for antibiotic treatment of cholecystitis. This patient was discharged to home within 24 hours after surgery, consistent with an ambulatory procedure. The patient could reasonably have undergone the laparoscopic cholecystectomy procedure at a lower level of care and been discharged the next day.