Diagnosis: cholecystitis
Treatment: inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld.

The patient is a female with medical history of myasthenia gravis status post thymectomy. She presented to the emergency department with right upper quadrant abdominal pain and postprandial vomiting. Vital signs were unremarkable. Physical examination was notable for focal abdominal tenderness and normal bowel sounds. Labs showed low hemoglobin of 12.1 with normal hematocrit, and unremarkable comprehensive metabolic panel. Right upper quadrant ultrasound showed findings suspicious for acute cholecystectomy with stone in the gallbladder neck and thickened gallbladder wall measuring 6 millimeter (mm), without pericholecystic fluid. She was treated with intravenous fluids, morphine, Zosyn, and acetaminophen. She was made nil per os (NPO). Surgery consultation concluded that she had acute versus acute on chronic cholecystitis.

The inpatient hospital stay is not medically necessary. The patient presented with right upper quadrant abdominal pain, and imaging was concerning for acute cholecystitis. However, there was no persistent hemodynamic instability or other complications such as ascending cholangitis, hepatic abscess, active gastrointestinal bleeding, peritonitis, fistula, or sepsis, which would require a higher level of care. The Laparoscopic cholecystectomy was not complicated by postoperative pneumonia, bile leak, bleeding, sepsis, or other complications. The care provided, including monitoring, labs, imaging, Surgery consultation, and cholecystectomy could have been performed in sequence after presentation, without the need for the inpatient level of care. For these reasons, the patient could have been cared for at a lower level of care.