Diagnosis: Cholecystitis.
Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission. The denial is upheld.

The patient presented to the Emergency Department with recurrent epigastric and right upper quadrant pain. She had been diagnosed with acute cholecystitis during a previous hospitalization but had declined surgery and was discharged on oral antibiotics. She returned to the emergency department with recurrent abdominal pain and underwent an uncomplicated laparoscopic cholecystectomy. The patient was discharged to home following an unremarkable postoperative course.

The literature confirming the safety and efficacy of outpatient laparoscopic cholecystectomy (LC) has been well established. As Lillemoe et al. (1999) have noted, laparoscopic cholecystectomy has achieved universal acceptance as the "gold standard" for the treatment of cholelithiasis and cholecystitis. Many centers have utilized "short-stay" units for post-operative observation following a laparoscopic cholecystectomy. These authors retrospectively analyzed 130 consecutive patients undergoing LC in an outpatient surgery unit. There were no conversions to an open procedure. Eight patients (6.2%) were admitted to the hospital directly from the post anesthesia care unit (PACU), and 6 of these patients were discharged to home on post-operative day 1. An additional 6 patients (4.6%) required hospital admission following discharge from the PACU, and 3 of these 6 patients were also discharged on post-operative day 1. These authors concluded that laparoscopic cholecystectomy can safely and effectively be performed "as a true outpatient procedure with patients being discharged to home within hours of completion of the procedure". Less than 10% of patients will require hospital admission, and less than 5% of patients may require hospitalization following discharge to home.

There is no documentation that the patient had a high risk of thromboembolism due to atrial fibrillation, a mechanical heart valve, or venous thromboembolism which would require inpatient anticoagulation. There is no documentation of perioperative or postoperative complications, co-morbid conditions, or hemodynamic instability that would require more intensive monitoring or management in the acute setting. The care that was received could safely and effectively have been performed on an outpatient basis.

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 level of care is not substantiated.