Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute Appendicitis 
Treatment: Hospital admission

The insurer denied coverage for hospital admission.
The denial is upheld.

According to the documentation submitted, this is a patient with no past medical history who was initially hospitalized for management of an acute perforated appendicitis. The patient was transferred to another hospital for specialist care for appendicitis. The patient was admitted to the hospital and had a computed tomography (CT) scan of the abdomen which revealed acute perforated appendicitis with localized extraluminal air, free fluid in the pelvis. His white blood count (WBC) then was 10.9.  He was admitted for medical management which included NPO [nothing given orally], IV (intravenous) fluid, nasogastric (NG) IV antibiotics and pain control. Repeat CT scans showed complex fluid collection with possible phlegmon. Subsequent CT scans showed increased fluid collections. No surgical or invasive radiological intervention was taken during his stay. His abdomen was tender diffusely, more in the right lower quadrant (RLQ). He was treated conservatively with IV antibiotics and IV fluids with multiple CT of the abdomen done. Repeat CT showed multiloculated abscess with a WBC of 17.3. Minimal chart was sent but evidently, he was transferred as a direct admission. 

Based upon the records provided the patient did not require acute inpatient admission since he could have been managed in an observation status. Furthermore, he was transferred for further management for IR (interventional radiologist) drainage, but the decision was made that he did not need it. Thus, he did not need to be transferred at that point in time. In fact, when he was transferred, he was afebrile with a normal WBC. He could have been treated with IV antibiotics via a peripherally inserted central catheter (PICC) line if necessary and treated as an outpatient. He did not require an inpatient stay for this. 

According to Milliman Care Guidelines (MCG) Health Inpatient and Surgical Care 25th Edition Appendectomy, with Abscess or Peritonitis S-180 the goal length of stay is 3 days. In this case appendectomy could not be performed but had to be delayed and the patient would require an interval appendectomy later. Thus, the whole reason for his stay was the treatment of the abscess which was not drained by IR. Thus, his whole management could have been under observation and not an acute admission. In fact, MCG notes extended stay beyond goal length of stay may be needed for: complications such as wound infection, intra-abdominal abscess, or fecal fistula one can expect a brief stay extension which is 1-3 days. And in this case his extended stay should have been at the hospital where he was receiving frequent CT scans and IV antibiotics. An IR intervention if needed should have been attempted much sooner than when he was transferred, he did not need an IR drainage which was the reason why he was being transferred.

This patient did not have any indication for admission-based MCG General Recovery Care 25th edition General Admission Criteria GRG: CG-GAC (ISC GRG) as it was known he had an abscess and was being treated with IV antibiotics. The decision to transfer was solely for an IR drainage which never happened. Thus, he did not need the inpatient admission. 

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

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