Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis
 
Treatment: Inpatient hospital stay

The insurer denied coverage for inpatient hospital stay. The denial is upheld. 

This patient is a female child with no significant past medical history who was transferred from one hospital to the ED of another with a complaint of confirmed appendicitis by CT. She presented to the ED in no acute distress. She was febrile to 100.7. Exam revealed the abdomen to have positive rebound and diffusely mild tender to palpation. As per the progress note the CT was read by Radiology and reviewed with Surgery and no appendicitis was seen. The plan was to monitor and for Surgery to re-evaluate in the morning. A progress note from surgery indicated the patient had a soft abdomen with non-distended and mildly tender, with no plan for surgical intervention at that time. The surgeon then noted that he reviewed the CT with Pediatric radiology who thought that the CT was abnormal and that they thought it was appendicitis. Given the overall scenario, the decision was made to take the child to the operating room for a laparoscopic appendectomy. Ultrasound of the appendix did not visualize the appendix. 

As per the operative note given her constellation of symptoms and her concerning CT scan the surgeon recommended lap appendectomy. She underwent an uneventful laparoscopic appendectomy. Findings included a mildly injected and dilated distal appendix with no evidence of perforation. The pathology report revealed appendicitis with luminal pinworm. There was no transmural inflammation and no histologic evidence of acute appendicitis. Post-operatively the patient did well, and the patient was discharged to home.

The patient did not need further acute care following the appendectomy except for the usual observation as noted. She did not have any sign of an abscess or perforation at the time of surgery and did not have signs of generalized peritonitis. She was observed and discharged which all could have been done within a 23 hour observation period. Medical necessity of acute inpatient hospitalization was not warranted, as the patient was afebrile and tolerating pain. There was no evidence of a complicated post op course requiring hospitalization. Therefore, the patient only required observation. Medical necessity of acute inpatient hospitalization was not warranted.

As per MCG- Health Inpatient and Surgical Care 23rd Edition Appendectomy, uncomplicated, open or laparoscopic ORG: P-20 (ISC) the Operative Status Criteria is ambulatory for most children with acute, uncomplicated, non-perforated appendicitis and those undergoing interval appendectomy after non-operative treatment. It is inpatient for children with complicated appendicitis (e.g. perforated without generalized peritonitis) or for those requiring prolonged (e.g., more than 24 hours postoperatively) care after surgery (e.g., co morbid illness). The goal length of stay is ambulatory or 1 day postoperative. 

To summarize, the inpatient hospital admission was not medically necessary at the acute care level as the patient could have been placed on an observation status. The health care plan did act reasonably and with sound medical judgment.  

Based on the above, the medical necessity for the inpatient hospital stay for date of service specified is not substantiated. The insurer's denial is upheld.