Diagnosis: Acute Cholecystitis
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient hospital admission.
The health plan's determination is upheld.

The patient is a female who was 9-weeks post-partum when she presented to the emergency department (ED) with abdominal pain, nausea, and vomiting of 1-day duration. She had known gallstones. At the time of presentation, the patient was without fever, her heart rate was 81 beats per minute, and her blood pressure was 131/71 millimeters of mercury (mmHg). She was tender in the right upper quadrant. The white blood cell count (WBC) count was normal at 7.2. The complete metabolic panel identified elevated liver enzymes (alanine aminotransferase (ALT) of 677 and aspartate aminotransferase (AST) of 545) and bilirubin of 1.2.
The ultrasound showed a gallbladder with gallstones and the bile duct was 3 millimeters (mm) in diameter. A magnetic resonance cholangiopancreatography (MRCP) was performed showing gallstones in the gallbladder and no findings of common duct stones. She was admitted to the hospital and was initially treated with intravenous (IV) fluids and antiemetics. She was treated with a laparoscopic cholecystectomy. The operative dictation records completion of the procedure without complication with findings of acute cholecystitis. The patient was treated with post-surgical monitoring, IV (intravenous) fluids, IV analgesia, antibiotics, and antiemetics. The immediate post-surgical recovery was uncomplicated. She had a normal temperature and normal vital signs. The diet was advanced, and her pain was controlled with oral medications. The patient remained clinically stable and was discharged from the inpatient setting.

An inpatient level of care was not medically necessary in this case. The treatment plan in this case included surgery that was performed. The progress notes state that the patient was stable for discharge from the hospital on the first post-surgical day. The ultrasound showed a gallbladder with gallstones and the bile duct was 3 millimeters (mm) in diameter. A magnetic resonance cholangiopancreatography (MRCP) was performed showing gallstones in the gallbladder and no findings of common duct stones. She was admitted to the hospital and was initially treated with intravenous (IV) fluids and antiemetics. She was treated with a laparoscopic cholecystectomy. The operative dictation records completion of the procedure without complication with findings of acute cholecystitis. There were no peri-operative complications or other clinical issues. She remained stable and was suitable for discharge from the hospital on the first post-surgical day. In this case, the patient's presenting condition, laboratory data and imaging, and her clinical course did not justify an inpatient level of care. The care provided during this period of time could have appropriately been rendered with an alternate level of care.

The health plan's determination of medical necessity is upheld in whole.