Diagnosis: Epigastric and periumbilical abdominal pain.

Treatment: Inpatient stay.

The insurer denied coverage for the inpatient stay.

The denial is upheld.

This is a female patient who presented to the Emergency Department (ED) with a one-day history of epigastric and periumbilical abdominal pain. There was associated nausea and vomiting. The patient's vital signs in the ED were within normal limits. The patient's ultrasound revealed "gallbladder calculi with mild gallbladder wall thickening and mild pericholecystic fluid." The patient's computed tomography (CT) scan demonstrated the same findings as the ultrasound. The patient's total bilirubin was within normal limits, but the direct bilirubin was slightly elevated at 0.7. The patient's alkaline phosphatase, alanine transaminase, and aspartate aminotransferase were all elevated at 321, 370, and 637, respectively. The patient's white blood cell (WBC) count was also within normal limits. The result of the patient's magnetic resonance cholangiopancreatography (MRCP) performed due to the elevated liver function tests, was "no choledocholithiasis or biliary ductal dilatation." The patient was taken to the operating room (OR) for a laparoscopic cholecystectomy. There were no reported complications. There were no reported postoperative complications. The patient was discharged within 24-hours after the procedure. There were no reported complications or indications for a delay in surgical intervention after all imaging studies were completed.

As per literature review, acute cholecystitis and biliary complaints are a common inpatient diagnosis. Acute cholecystitis is also estimated to attribute to millions of ambulatory visits each year, and is a leading cause of hospital admissions.1 Studies have shown that ambulatory laparoscopic cholecystectomy is safe and avoids an overnight hospital stay.2,4,5 Factors that contribute to admission after laparoscopic cholecystectomy include drain placement, conversion to open surgery, persistent abdominal pain, nausea, and vomiting.3 In patients without abnormalities of the bile duct or abnormal liver function tests, ambulatory laparoscopic cholecystectomy is safe and feasible.5,6

Based on the review of the medical record and literature, laparoscopic cholecystectomy can successfully be performed as an outpatient/ambulatory procedure. The inpatient admission was not medically necessary for this patient.

The health plan acted reasonably with sound medical judgment, and in the best interest of the patient.

The insurer's denial of coverage for the inpatient stay should be upheld. The medical necessity is not substantiated.