Appeal type: Medical necessity
Decision: Upheld

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

According to the documentation submitted, this is a patient who presented to the emergency department (ED) for abdominal pain for 1 week. The patient was seen in the ED the day prior and labs were unremarkable and with improvement of pain the patient was sent home. The patient returned to the ED as the pain persisted and migrated to the right lower quadrant (RLQ) with positive McBurney's point. Labs and computed tomography (CT) were obtained which showed appendicitis. As per the ED provider note, the patient has a history of asthma and is likely to have appendicitis. General surgery was paged and the plan was to admit to surgery. White blood cell (WBC) count was 6.8.

Surgery admission note indicated the patient presented with 1 month of pain and possible gastritis. The patient now continued to have abdominal pain with mild lower abdominal tenderness localizing to the RLQ. CT taken in the ED revealed a 1 centimeter (cm) dilated appendix with findings suspicious for uncomplicated appendicitis. Exam revealed abdominal tenderness. The patient was made nothing by mouth (NPO) and was to be booked for lap appendectomy.

The patient underwent an uneventful lap appendectomy. Findings on path included severe acute appendicitis with abscess formation.

Post operation, the patient did well and was discharged.

Based upon the records provided, it is agreed that the patient did not require acute inpatient admission since the patient should have been managed in an observation status. The patient did not require an acute inpatient admission but rather observation status as they did not have any surgical complications from the surgery that warranted inpatient care. The lap appendectomy was uneventful, and this was a non-perforated appendicitis. 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 operation or surgical site infection, diet tolerated, pain absent or managed, no evidence of ileus or bowel obstruction, oral medications and oral diet. 

Furthermore, MCG Health noted in General recovery care 27th edition General admission criteria GRG: CG-GAC (ISC GRG) that admission is indicated for 1 or more of the following: hemodynamic instability, acute cardiac or peripheral ischemia, cardiac arrhythmias of immediate concern, severe respiratory findings, etc ("and the rest").  Based upon these guidelines, this patient should have been observed rather than placed in an acute admission as the patient did not have any indication as noted above for inpatient stay or prolonged stay. The patient did not need acute inpatient admission but rather observation status. In fact, the patient was discharged within 23 hours of admission. The patient had a non-perforated appendicitis and underwent an uneventful lap appendectomy; this is an ambulatory procedure as the insurer noted. 

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

The medical necessity for the inpatient hospital stay is not substantiated.