Diagnosis: Cholecystitis
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a male patient who presented to the emergency department (ED) with a complaint of new onset abdominal pain. His past medical history is significant for diabetes The vital signs were normal at the time of presentation. The white blood cell count (WBC) count was normal at 10.4 thousand (K). Liver enzymes and bilirubin were elevated. The patient was admitted to the hospital and started on intravenous (IV) antibiotics. The surgical history and physical (H&P) states that he had tenderness in the right upper quadrant. An ultrasound showed gallstones in the gallbladder, a thickened gallbladder wall and pericholecystic fluid.
The patient underwent a laparoscopic cholecystectomy. The operative dictation describes that cholecystectomy was performed without complication. There were findings of cholecystitis. His vital signs were normal and the patient was tolerating food. His glucose was elevated. The WBC count and liver enzymes/bilirubin were improved.
An endocrinology consultation was obtained for recommendations regarding his diabetes management. The patient's diet was advanced and pain was controlled with oral medications. His vital signs were normal. The patient remained clinically stable and was discharged from the inpatient setting with instructions for surgical and endocrinology follow up. At issue is the medical necessity of an inpatient stay.

An inpatient level of care was not medically necessary in this case. This patient presented to the hospital with the complaint of abdominal pain. At the time of presentation, the patient had normal vital signs and was clinically stable. His evaluation identified gallstones. Surgical consultation was obtained and the patient underwent a laparoscopic cholecystectomy .
There is no documentation of hemodynamic, pulmonary, neurological, or metabolic reason for an acute inpatient level of care at the time of presentation. Additionally, there is no documentation of failure to achieve discharge criteria, conversion to open surgery, care for comorbidities, procedural complications, or any other condition requiring inpatient admission.
In the early post-surgical recovery, the patient was noted to have elevated glucose levels and was evaluated with endocrinology consultation (prior to discharge) for recommendations on diabetes management. He was advanced on a diet and lab data showed improvement in liver enzymes and bilirubin. Acute inpatient care was not medically necessary for this patient as the care and treatment provided could have been rendered with a lower level of care.
A lower level of care would have provided for initial assessment, perioperative care and monitoring, provision of intravenous (IV) fluid, surgical consultation, performance of cholecystectomy, and overnight monitoring. There were no peri-procedure complications or other clinical issues that mandated an inpatient level of care.