Diagnosis: Cholecystitis.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The determination is overturned.

This is a female patient who presented with right upper quadrant abdominal pain, nausea, vomiting and irregular bowel movements. She had a subjective fever and was unable to keep anything down. She was hemodynamically stable in the emergency room (ER) but had right upper quadrant (RUQ) tenderness with a positive Murphy's sign. Her lab results showed a white blood cell count (WBC) of 11.1. Her urinalysis (UA) was positive with white blood cell (WBCs) and squamous cells. A computed tomography (CT) scan of the abdomen and pelvis showed gallbladder wall thickening and a stone in the gallbladder fundus without any obstruction. She was given intravenous (IV) morphine, IV fluids and antibiotics. General surgery was consulted, and they recommended admission and possible surgery. An ultrasound (US) of the abdomen was also recommended. However, the patient had a family emergency and decided to leave against medical advice (AMA). She was prescribed antibiotics and was discharged. At issue is the medical necessity of an inpatient stay.

Based on a review of the medical records and the literature, the inpatient admission was medically necessary and supported by the literature. The patient had classic symptoms of acute cholecystitis that were confirmed by abdominal imaging. She had nausea, vomiting and poor oral intake. She left against medical advice but she was a good surgical candidate and admission and laparoscopic cholecystectomy was recommended and standard of care. Ideally, a cholecystectomy should be performed within 3 days of symptom onset. According to a review, following diagnosis, early (performed within 1-3 days) versus (vs) late (performed after 3 days) laparoscopic cholecystectomy is associated with improved patient outcomes, including fewer composite postoperative complications (11.8 percent (%) for early vs 34.4% for late), a shorter length of hospital stay (5.4 days vs 10.0 days), and lower hospital costs. According to this study, the average length of stay was 5.4 days in patients undergoing laparoscopic cholecystectomy [1]. Per Milliman Care Guidelines (MCG), patients who have classic cholecystitis symptoms as this patient had and who have signs of systemic illness (WBC greater than (>) 10 thousand (K)), inpatient admission is recommended. Although the patient left AMA, the inpatient admission was indicated and a medical necessity. The patient had classic symptoms of cholecystitis, and had radiographic evidence and an indication for urgent cholecystectomy.