Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis.

Treatment: Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission.

The denial is upheld.

This patient is a male child who presented to the Emergency Department (ED) via Emergency Medical Services (EMS) with complaints of right lower quadrant (RLQ) abdominal pain. The patient was seen in the ED of an outside hospital (OSH) with abdominal pain and was confirmed to have appendicitis. He was transferred from the OSH for surgery. The patient received ceftriaxone and Flagyl. The patient's white blood cell (WBC) count was 12. The patient's computed tomography (CT) scan showed acute appendicitis. The patient's ultrasound revealed hyperemic appendix with thick walls and maximum diameter up to 9 millimeters (mm) consistent with acute appendicitis. The patient was admitted with the plan for laparoscopic (lap) appendectomy. The patient was taken to the Operating Room (OR) on day 2 of admission. The patient underwent an uneventful lap appendectomy. There was no evidence of perforation. Pathology revealed acute appendicitis with serositis with prominent subserosa lymphoid aggregates.  The patient tolerated the procedure well and was advanced on diet. The patient was cleared for discharge later on in the day on day 2 of admission.  

As per the Milliman Care Guidelines (MCG)- Health Inpatient and Surgical Care 24th Edition Appendectomy, uncomplicated, open or laparoscopic, the Operative Status Criteria is ambulatory with the goal length of stay is ambulatory. Extended Stay as defined by Minimal (a few hours to 1 day), Brief (1 to 3 days), Moderate (4 to 7 days), and Prolonged (more than 7 days) may be needed for: failure to achieve discharge status; prolonged fever and prolonged fever may require longer observation in hospital on parenteral antibiotics and one can expect brief stay extension; complicated appendicitis with discovery or development of generalized peritonitis or intra-abdominal abscess may require longer observation on parenteral antibiotics; complications such as wound infection, intra-abdominal abscess, fecal fistula, pylephlebitis, and intestinal obstruction may occur and require continued observation or reoperation and one can expect brief to moderate stay extension; prolonged ileus with prolonged ileus may delay initiation of feeding and one can expect brief stay extension; or postoperative bleeding may require reoperation and one can expect brief stay extension. In this case, the patient had an uncomplicated non-perforated appendicitis and did not have any complication post- surgery. The patient was tolerating his diet and could have been cared for under an Observation Status (ambulatory setting); therefore, he did not require an acute care inpatient admission. 

Based on the review of the medical record and literature, the patient did not require the acute inpatient stay with hospital admission as the patient could have been cared for based upon a 23-hour observation admission. The patient did not need further acute care following the appendectomy except for the usual observation as noted. The patient did not have any clinical sign of an abscess or perforation at the time of surgery and did not have signs of generalized peritonitis. The patient was observed and discharged which all could have been done within a 23-hour observation period. The medical necessity of an acute inpatient hospitalization was not warranted, as the patient was stable postoperatively. There was no evidence of a complicated postoperative course requiring hospitalization. The patient only required observation. An acute inpatient stay was not medically necessary for this patient.

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

The carrier's denial of coverage for the inpatient hospital admission should be upheld. The medical necessity is not substantiated.