Diagnosis: Abdominal pain

Treatment: Inpatient admission

The insurer denied coverage for an inpatient admission

The denial is upheld

Acute cholecystitis is 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] Ambulatory and/or outpatient laparoscopic cholecystectomies reduce hospital costs without compromising patient outcomes.[6]

Per clinical documentation, this patient presented to the ED (emergency department) with a one-day history of acute right upper quadrant abdominal pain. There was associated nausea without vomiting. Vital signs in the ED were within normal limits. The patient had a CT (computed tomography) scan that demonstrated cholelithiasis without evidence of cholecystitis. White blood cell count was slightly elevated at 11.7. The patient was taken to the operating room for a laparoscopic cholecystectomy. There were no reported complications. Per MCG (Milliman Care Guidelines) criteria, admission is indicated for calculus or obstruction of gallbladder or bile duct and either hemodynamic instability, common bile duct obstruction, severe or persistent vomiting or dehydration, severe pain, or bacteremia. According to clinical documentation, the patient did not meet criteria for an inpatient admission. Peer-reviewed literature indicates that laparoscopic cholecystectomy can successfully be performed as an outpatient procedure. Therefore, the requested hospital stay should be billed as observation status. Inpatient admission is not medically necessary.

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

The insurer's denial of coverage for the inpatient hospital admission is upheld. Medical Necessity is not substantiated.