Diagnosis: Cholelithiasis.
Treatment: Inpatient admission.
The insurer denied coverage for inpatient admission.
The denial is upheld.

The patient presented with right upper quadrant (RUQ) abdominal pain. She was previously found to have cholelithiasis and elevated liver enzymes. A magnetic resonance cholangiopancreatography (MRCP) did not show common bile duct (CBD) stones. By the time of admission her pain had resolved. She was afebrile and the vital signs were stable. The abdominal exam was benign. There was no leukocytosis. An abdominal ultrasound showed gallstones but not acute cholecystitis. A hepatobiliary scintigraphy (HIDA) scan was negative. An Endoscopic ultrasound (EUS) was negative for bile duct obstruction. There was a plan to do an outpatient cholecystectomy.

Clinical indications for admission for Gallbladder or Bile Duct Stone or Inflammation (Milliman Care Guidelines (MCG) M-555) include having acute cholecystitis or acute cholangitis if certain indications are met. In this case, the patient did not have either acute cholecystitis or acute cholangitis. Other indications for admission for gallbladder calculus include hemodynamic instability, severe vomiting, severe dehydration, bacteremia, or CBD obstruction. She did not have these conditions.

This patient had gallbladder disease but did not have either acute cholecystitis or acute cholangitis. No emergency surgical interventions were required. Intravenous (IV) hydration and monitoring of the liver enzymes could have been done with observation status. She did not meet MCG criteria for admission for Gallbladder or Bile Duct Inflammation or Stone.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient.

The medical necessity for the inpatient hospital admission is not substantiated.