Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute Appendicitis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld.

This patient has a past medical history of hypertension, hypercholesterolemia, pre-diabetes, and morbid obesity status post sleeve gastrectomy. She presented with complaints of severe lower abdominal pain with associated nausea but no emesis. Vital signs upon presentation to the emergency department included blood pressure of 114/78, pulse of 86, temperature of 98.8, respiratory rate of 16, 100% (percent) oxygen (O2) saturation on room air. Physical examination demonstrated tenderness in the right lower quadrant and left lower quadrant with guarding and rebound, no costovertebral angle (CVA) tenderness, and a positive psoas sign. Laboratory studies showed a normal white blood count (WBC) of 9.2, hemoglobin of 9.3, and a platelet count of 369. Computed tomography (CT) of the abdomen and pelvis showed acute appendicitis without peri appendiceal fluid collection. The patient received a 1 liter bolus of normal saline, famotidine, cefoxitin, metoclopramide, and morphine. The patient was transferred. Vital signs upon arrival to the next facility remained stable, with blood pressure 116/73 pulse 91 respiratory rate 18 temp 98.1. She received IV (intravenous) Cefoxitin 1 gram (gm), a liter of lactated Ringer's solution, and IV Fentanyl 25 microgram once. She was admitted with an inpatient status to the surgical service and underwent a laparoscopic appendectomy. Intraoperative findings revealed no evidence of gangrene or perforation. A 4-hour post-operative check noted that the patient had pain minimally relieved by Tylenol, no appetite, nausea, or vomiting. She had also urinated and was ambulating without assistance. The patient had an uneventful postoperative course, and her pain was controlled with medication. Her diet was advanced as tolerated. At the time of discharge, the patient was tolerating a diet without nausea or vomiting, having bowel function, and ambulating without assistance. 

Frazee et al analyzed the data from seven institutions that had adopted an outpatient laparoscopic appendectomy protocol for uncomplicated appendicitis. Patients were discharged unless there was a clinical indication for admission. There were a total of 376 patients, 299 of whom (80%) were managed as outpatients. Seventy-eight patients (21%) had pre-existing comorbidities, and 12 patients (3%) required readmission. Post-operative morbidity occurred in 5% of patients, and there were conversions to open appendectomy. Their study concluded that the outpatient laparoscopic appendectomy protocol was successfully applied at multiple institutions with low morbidity and low readmission rates. 

In summary, the patient was admitted as an inpatient for acute appendicitis and underwent a laparoscopic appendectomy. She remained stable with normal vital signs and an unremarkable post-operative course. The patient was ambulating without assistance and tolerating oral intake 4 hours following the laparoscopic appendectomy. Her pain was adequately controlled with medications. The patient did not require inpatient services following her appendectomy. She had no evidence of fever, tachycardia, or medical instability. There was no evidence of a post-operative complication that would require close monitoring or further treatment. The appendix was not gangrenous or perforated, and there was no evidence of an abscess that would require prolonged intravenous (IV) antibiotic therapy. Therefore, the medical necessity for the inpatient admission has not been established. The care that was received could safely and effectively have been performed on an outpatient basis. The health plan acted reasonably and with sound medical judgement and in the best interest of the patient. 

The insurer's denial of coverage for the inpatient admission is upheld. Medical necessity is not substantiated.