Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld

This patient is an adult female who presented to the emergency department with the complaint of abdominal pain and fever of two-days duration. Comorbid health conditions included hypertension, gastroesophageal reflux disease (GERD) and prior pulmonary embolism (not on current anticoagulation). The patient's examination revealed epigastric tenderness. Vital signs identified a normal temperature and normal vital signs at the time of presentation. The white blood cell (WBC) count was elevated at 16 thousand. Surgical consultation was obtained. Computed tomography scan was completed showing findings of acute appendicitis with surrounding periappendiceal fat stranding, but no evidence for perforation. The patient was admitted to the hospital and started kept on intravenous antibiotics. On the next day, the patient reported improvement in her abdominal pain and the white blood cell (WBC) count was down to 9.9 thousand.
Vital signs were consistently normal. She was transitioned to oral medications and diet. She was discharged from the hospital on the second day with instructions for surgical follow up for interval appendectomy. The health plan rationale for denial is that there is no documentation of need for an inpatient level of care and the care rendered could have been provided without admission to the hospital. This letter references Milliman Care Guidelines (MCG), Gastroenterology.

The proposed treatment was not medically necessary.

Inpatient care was not medically necessary for this patient. This patient presented to the emergency department and was evaluated with physical exam, labs and imaging that supported the diagnosis of acute appendicitis. She was treated initially with nothing by mouth (NPO) status, intravenous (IV) fluids and intravenous antibiotics. A nonsurgical approach was undertaken. The patient had a normal white blood cell count and was started on a diet. Her clinical course was without adverse incident. The patient responded favorably to this treatment and the hospitalization was uncomplicated. The patient had no comorbid health conditions that mandated an inpatient level of care, and the vital signs were consistently normal. The progress notes document clinical stability without complication during this period of monitoring. The submitted clinical documentation does not support the need for inpatient admission for this patient. A lower level of care would have satisfactorily provided for the care rendered and would have been consistent with the accepted standard of medical care. Generally accepted medical standards indicate that in the absence of hemodynamic instability, sepsis or toxicity, significant electrolyte imbalance, bleeding, gastrointestinal (GI) obstruction or surgical complications, treatment as provided in this case could be provided without an inpatient level of care. In this case the patient tolerated oral hydration on day #1 and a treatment plan was established with plan for continued oral antibiotics, outpatient follow up and possible interval appendectomy. A lower level of care would have appropriately provided for treatment and monitoring. Inpatient care was not required or medically necessary in this case per generally accepted medical standards.