Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute Appendicitis. 
Treatment: Full Hospital Admission. 

The insurer denied coverage for full hospital admission. 
The denial is upheld. 

The patient is an adult male with past medical history of hypertension (HTN) who presented to the emergency department (ED). As per the History and Physical, he presented with complaints of right lower quadrant (RLQ) pain for 2 days. He denied any radiation of pain. He was afebrile. Computed tomography (CT) of the abdomen revealed a fluid filled and dilated up to 1 cm (centimeters) appendix with mild peri-appendiceal inflammatory changes consistent with acute appendicitis. He denied nausea, vomiting or fever. There was no evidence of abscess or perforation. The patient was admitted to surgery and consented for lap appendectomy. White Blood Cell count was 8.7. He was taken to the operating room for an uneventful lap appendectomy. The appendix had multiple nodules. He did well postop and was discharged. 

According to Milliman Care Guidelines (MCG) Inpatient and Surgical Care 26th Edition Appendectomy, without Abscess or Peritonitis, by laparoscopy 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 could have been discharged following observation. 

According to MCG, the operative status criteria is ambulatory. MCG also notes extended stay may be indicated and defined as Minimal (a few hours to 1 day), Brief (1 to 3 days), Moderate (4 to 7 days), and Prolonged (more than 7 days). Inpatient stay may be needed for: Failure to achieve discharge status criteria; Complicated appendicitis with discovery or development of peritonitis, intra-abdominal abscess, or prolonged fever may require conversion to an open procedure or longer observation on parenteral antibiotics and one can expect brief stay extension; clinically active comorbidities (require more prolonged postoperative care) and anticipate treatment directed at particular comorbidity (e.g., congestive heart failure [CHF], acute kidney injury (Stage 2)), Acute renal failure (Stage 3 acute kidney injury), chronic obstructive pulmonary disease [COPD], cirrhosis)s, or surgery may be delayed pending medical optimization of comorbid conditions and one can expect brief stay extension; Complications such as wound infection, wound dehiscence, or enterocutaneous fistula and require continued observation, percutaneous drainage, or reoperation and one can expect brief stay extension;  Continued ileus with inability to tolerate oral intake may require continued stay and one can expect brief stay extension; Postoperative bleeding which may require reoperation and one can expect brief stay extension. The patient did not have any comorbidities that required treatment at the time that would have extended his stay. He did not have peritonitis. He did not require any significant preop optimization prior to going to surgery. 

Analysis of procedure data for a large adult population shows 85% of laparoscopic appendectomies performed on patients with appendicitis without peritonitis or abscess being performed on an outpatient basis. The patient was admitted and underwent an uneventful lap appendectomy - all of which should have been done in an observation status with discharge. 

The health plan acted reasonably with sound medical judgment in the best interest of the patient. 

The insurer's denial of coverage for the full hospital admission is upheld. Medical Necessity is not substantiated.