Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

According to the documentation submitted, this is a patient who presented to the emergency department (ED) for abdominal pain and nausea. As per the ED history and physical, the patient has a history of nephrolithiasis, gastritis, and gastroesophageal reflux disease (GERD) and presented with abdominal pain. The patient was afebrile with stable vital signs. The patient had tenderness in the right upper quadrant (RUQ) and periumbilical area. The assessment was high level of concern for appendicitis versus cholecystitis given region of tenderness. Gastroenteritis was also to be considered. A computed tomography (CT) noted appendicitis with no free air or free fluid.  General surgery was consulted and recommended antibiotics. White blood cell count (WBC) was 11.5. The plan was laparoscopic appendectomy. 

The patient underwent an uneventful laparoscopic appendectomy. Findings on path included acute appendicitis with acute inflammation in the periappendiceal fat.

Postoperatively in the post-anesthesia care unit (PACU) the patient was placed on continuous positive airway pressure (CPAP) for desaturation. The plan was to continue to monitor. Postop progress notes indicated the patient's post op (postoperative) course was complicated by intermittent decreased saturations requiring bilevel positive airway pressure (BIPAP). Postop the patient developed acute urinary retention requiring a Foley catheter. Urology was called for this and the patient required Foley catheter to be placed.

Patient was seen by pulmonary who noted no need for BIPAP while awake. Pulmonary noted the patient will require outpatient sleep studies.

The patient continued to improve and was discharged with Foley removed.

Based upon the records provided, the patient did not require acute inpatient admission; the patient should have been managed in an observation status as they did not have any surgical complications from the surgery that warranted inpatient care. Acute urinary retention is not an indication for acute admission. In addition, the patient desaturating only meant they had to be monitored and given CPAP/BIPAP for undiagnosed obstructive sleep apnea (OSA). The lap appendectomy was uneventful, and this was a non-perforated appendicitis. Thus, the patient should have had the appendectomy performed under an observation status without acute inpatient admission. According to Milliman Care Guidelines (MCG) Health Inpatient and Surgical Care 27th Edition Appendectomy, without Abscess or Peritonitis, by laparoscopy ORG: S-175 (ISC) optimal recovery course includes floor to discharge with the following milestones completed: hemodynamic stability; procedure completed; no evidence of post op or surgical site infection; diet tolerated; pain absent or managed; no evidence of ileus or bowel obstruction; oral medications and oral diet. Based upon the records provided, the patient reached these milestones, and should have been discharged following observation. In addition, the operative status criteria is ambulatory. Given this the patient did not require admission but ambulatory status with observation. 

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 admission is not substantiated.