Diagnosis: Acute Cholecystitis

Treatment: Inpatient Admission

The insurer denied coverage for Inpatient Admission

The denial is upheld

Acute cholecystitis is also estimated to attribute to millions of ambulatory visits each year and is a leading cause of hospital admissions. [1] Studies have shown that ambulatory laparoscopic cholecystectomy is safe and avoids an overnight hospital stay. [2, 4, 5] Factors that contribute to admission after laparoscopic cholecystectomy include drain placement, conversion to open surgery, persistent abdominal pain, nausea, and vomiting. [3] In patients without abnormalities of the bile duct or abnormal liver function tests (elevated alkaline phosphatase (ALP) and total bilirubin), ambulatory laparoscopic cholecystectomy is safe and feasible. [5, 8] A 50% (percent) increase in the liver function tests can be labelled as mild elevation and is considered negligible by many. [9] Ambulatory and/or outpatient laparoscopic cholecystectomies reduce hospital costs without compromising patient outcomes. [6]

Per clinical documentation, this patient presented to the Emergency Department (ED) on with epigastric abdominal pain. Vital signs in the ED were within normal limits (WNL). The patient was afebrile. Abdominal ultrasound demonstrated cholelithiasis without findings of acute cholecystitis. White blood cell (WBC) count was normal at 7.1k (7.1 thousand). Liver function tests were elevated with alanine transaminase (ALT) 130, aspartate aminotransferase (AST) 55, and alkaline phosphatase (ALP) 185. The patient underwent a laparoscopic cholecystectomy. There were no reported complications. There is no further clinical documentation of a need for inpatient admission. Per Milliman Care Guidelines (MCG) criteria, admission is indicated when common bile duct obstruction is indicated via imaging and there are signs of systemic inflammation. [7] Peer-reviewed literature and MCG criteria indicate that inpatient admission is not necessary. Per provided clinical documentation, inpatient admission was not medically necessary. Observation status would be more appropriate.

Case summary details

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 the inpatient admission is not substantiated