Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis 
 
Treatment: Inpatient Admission 

The insurer denied the Inpatient Admission. The denial was upheld. 

This is a male patient who presented to the emergency department with complaints of left sided abnormal pain that radiated to her right lower quadrant, with associated nausea and vomiting. Her presenting vital signs were blood pressure 131/89, heart rate 108, respiratory rate 18 and temperature 98.4. A laboratory work up was performed that revealed a magnesium level was 1.2, and lactic acid level was 2.8. A computed tomography (CT scan of the abdomen was performed that was consistent with acute appendicitis. The patient underwent a laparoscopic appendectomy without complications. He was medically stable and was discharged home. 

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, nonperforated appendicitis and those undergoing interval appendectomy after nonoperative 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. 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: 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. None of these situations were seen in this case as the patient had an uncomplicated, non-perforated appendicitis as noted in the medical record; and did not have any complication after the surgery. Based on this clinical presentation, the patient could have been cared for under an observation status (ambulatory setting), and therefore, did not require an acute care inpatient admission. 

MCG guidelines also noted that there are multiple studies that document length of stay of 1 day or less. For example, MCG noted "A multicenter observational study of 2617 pediatric patients with acute appendicitis (73% simple) and found a median length of stay of 1 day for both laparoscopic and open appendectomies. Another study of 360 pediatric patients with uncomplicated appendicitis who underwent laparoscopic appendectomy found a mean length of stay of 23 hours. A study of 92 pediatric patients who underwent laparoscopic appendectomy for uncomplicated appendicitis found that 92% of patients were able to be discharged in less than 24 hours, with a mean length of stay of 14 hours. Analysis of 295 pediatric patients undergoing appendectomy (82% laparoscopic) for uncomplicated appendicitis after the implementation of a clinical pathway found a mean length of stay of 24 hours. Analysis of national hospital discharge data for a pediatric population showed 72% of hospitalized patients undergoing a principal procedure of laparoscopic appendectomy for acute appendicitis without mention of peritonitis discharged in 1 day." Thus, literature supports that laparoscopic appendectomy can be done under an observation status with discharge within 24 hours of surgery. There was no clinical reason or indication that this patient needed hospital stay beyond 24 hours. 

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

Based on the above, the medical necessity for the inpatient hospital services at the inpatient level of care is not substantiated. The insurer's denial is upheld.