Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis.

Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is upheld .

According to the documentation submitted, this is a teenager who presented to the emergency department (ED). As per the ED provider note the patient presented with lower abdominal pain and subjective fevers for 2 days. The patient denied nausea or vomiting. She has been sexually active in the last month. She denied vaginal discharge and last menstrual period (LMP) was 5 days ago. She was afebrile and vital signs were stable. She had right lower quadrant (RLQ), suprapubic and left lower quadrant (LLQ) tenderness without guarding or rebound. The lower abdomen was tender to palpation without peritoneal signs. Bimanual exam revealed generalized tenderness. The assessment was appendicitis. Urine pregnancy was negative. The plan was computed tomography (CT) of the abdomen and labs. White blood cells (WBC) were 15.7. CT of the abdomen results revealed an appendicolith measuring 8 millimeters (mm) in diameter with findings suggestive of acute appendicitis. No peri appendiceal abscess was noted. General surgery was consulted. The patient was admitted to surgery. She was made nothing by mouth (NPO) and given intravenous (IV) antibiotics with plan for surgery.

The patient underwent an uneventful lap appendectomy with the findings of acutely inflamed appendix without purulent fluid noted. The appendix was not perforated. Pathology revealed severe acute transmural appendicitis and serositis. Post op the patient did well.

Based upon the records provided the patient did not require acute inpatient admission since she should have been managed in an observation status.  She did not require an acute inpatient admission but rather observation status as she did not have any complications from the surgery that warranted inpatient care. The laparoscopic appendectomy was uneventful, and this was a non-perforated appendicitis. There was no evidence of a complicated post op course requiring hospitalization. Thus, the patient should have had the appendectomy performed under an observation status without acute inpatient admission. 

According to Milliman Care Guidelines (MCG) Health Inpatient and Surgical Care 27th Edition Appendectomy, without Abscess or Peritonitis, by laparoscopy ORG: S-175 (ISC) 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 should have been discharged following observation within a 23-hour observation period following surgery. In addition the operative status criteria is ambulatory.   Given this the patient did not require admission but ambulatory status with observation. 

Based upon these guidelines this patient should have been observed rather than placed in an acute admission as she did not have any indication as noted above for inpatient stay or prolonged stay. She did not need acute inpatient admission but rather observation status. She had non-perforated appendicitis and underwent an uneventful lap appendectomy; and this is an ambulatory procedure.

The patient was admitted and underwent an uneventful lap appendectomy - all of which could have been done in an observation status. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient is not substantiated.