Diagnosis: Cholelithiasis

Treatment: Inpatient hospital services

The insurer denied coverage for inpatient hospital services

The denial is upheld

The patient had a history of alcohol abuse and presented with right upper quadrant (RUQ) abdominal pain. The patient was afebrile, and the vital signs were stable. There were no peritoneal signs. There was no leukocytosis. The patient had thrombocytopenia. There was elevation of the liver enzymes. An abdominal Computed Tomography (CT) scan showed cholelithiasis with suspected acute cholecystitis as well as a small liver mass. There was a plan for a laparoscopic cholecystectomy but it was canceled due to thrombocytopenia.

Clinical indications for admission for Gallbladder or Bile Duct Inflammation or Obstruction (Milliman Care Guidelines (MCG) M-555) include having acute cholangitis or acute cholecystitis. These conditions need to be manifested by systemic signs of inflammation as indicated by fever or leukocytosis. The patient did not have acute cholangitis. There was a concern about acute cholecystitis but the patient was not having systemic signs of inflammation. The patient also did not have hemodynamic instability, common bile duct (CBD) obstruction, severe vomiting, or bacteremia.

This patient had evidence of alcoholic cirrhosis and had gallbladder disease. It was decided not to proceed with surgery due to the thrombocytopenia that was caused by the cirrhosis. Intravenous (IV) hydration and antibiotics could have been given with observation status. The patient did not meet MCG criteria for admission for Gallbladder or Bile Duct Inflammation or Obstruction. The health care plan acted reasonably and with sound medical judgment. An inpatient admission was not medically necessary.

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 inpatient hospital services is not substantiated.