Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission.
The denial is upheld.

The patient is an adult with asthma and a previous open right inguinal hernia repair who presented with right-sided abdominal pain and tenderness associated with decreased appetite, nausea, and vomiting. The pain had started on the prior evening and was not relieved by Pepto Bismol, GasX, Tylenol, or a laxative that the patient had taken at home. His vital signs were within normal range upon presentation to the emergency department, and laboratory studies demonstrated leukocytosis, with a white blood cell count of 12.73. Computed tomography (CT) of the abdomen and pelvis was performed with intravenous (IV) contrast, demonstrating a dilated appendix measuring up to 1.1 centimeters (cm) with periappendiceal inflammatory stranding and a mid-appendiceal appendicolith consistent with acute appendicitis. IV fluids and IV Zosyn were initiated in the emergency department. The patient underwent a laparoscopic appendectomy with extensive lysis of adhesions for acute appendicitis. The appendix ruptured into the mesentery during the course of the dissection, and the spillage was promptly removed with suctioning. The patient did well following surgery, with stable vital signs, adequate pain control, and close observation in the post-anesthesia care unit. He was able to tolerate oral liquids and crackers and was ambulating around the unit without any issues. He was discharged to home the same day. The medical necessity for the inpatient admission of the patient has not been established. The care that was received could safely and effectively have been performed at an outpatient level of care, which encompasses close monitoring and administration of IV fluids, IV antibiotics, and IV analgesics as required. The outpatient level of care also provides the option to upgrade to an inpatient level of care if the clinical scenario changes and warrants more intensive monitoring or treatment. Therefore, the health plan acted reasonably and with sound medical judgement and in the best interest of the patient.

As previously noted, the patient was admitted as an inpatient for acute appendicitis and underwent a laparoscopic appendectomy. He 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 patient did not have any serious co-morbid conditions requiring close observation. The appendix ruptured during the course of the dissection, and the spillage was promptly removed. There was no evidence of an abscess that would require prolonged IV antibiotic therapy, and the patient was discharged home with a 5-day course of oral antibiotics. The care that was received could safely and effectively have been performed at an outpatient level of care, which encompasses close monitoring and administration of IV fluids, IV antibiotics, and IV analgesics as required. The outpatient level of care also provides the option to upgrade to an inpatient level of care if the clinical scenario changes and warrants more intensive monitoring or treatment.

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 inpatient admission is not substantiated.