Appeal type: Medical necessity
Decision: Upheld

Diagnosis: abdominal pain

Treatment: inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld.

According to the documentation submitted, this is an adult male with past medical history of seizures as a child who presented to the emergency department (ED).  As per the triage note, the patient presented with complaints of abdominal pain associated with nausea without vomiting. The patient was afebrile with stable vital signs. 

The pain initially began in the epigastrium. The patient had nausea but no vomiting. He had subjective fevers but denied chills. On exam he had right upper quadrant (RUQ) tenderness to palpation with positive Murphy's sign and right lower quadrant (RLQ) tenderness to palpation with positive Rovsing sign (right lower abdomen pain on left sided palpation) without rebound or guarding. He was admitted with the principal diagnosis of acute appendicitis. Computed tomography (CT) showed uncomplicated acute appendicitis without perforation or abscess collection noted. Surgery was consulted.  The patient was admitted to surgery. White Blood Cell (WBC) count was 13.11. The patient was nothing by mouth  and intravenous (IV) Zosyn was given. 

The patient was taken to the operating room for an uncomplicated lap appendectomy. After surgery the patient was given intravenous (IV) fluids and IV Dilaudid. The surgical sites were monitored for bleeding, swelling, and hematoma and the patient was discharged the same day. 

The laparoscopic appendectomy was uneventful. There was no evidence of a complicated post operative course requiring hospitalization and the patient was discharged within 23 hours (on the same day pf surgery). 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. 

Furthermore, Milliman Care Guidelines (MCG also notes that extended stay as defined by Minimal (a few hours to 1 day), Brief (1 to 3 days), Moderate (4 to 7 days), and Prolonged (more than 7 days) can be seen. Inpatient stay may be needed for: Failure to achieve discharge status criteria with  complicated appendicitis with discovery or development of peritonitis, intra-abdominal abscess, or prolonged fever may require conversion to an open procedure, percutaneous drainage, or longer observation on parenteral antibiotics and one can expect brief stay extension; clinically active comorbidities (require more prolonged postoperative care) and anticipate treatment directed at particular comorbidity..." Thus observation/ ambulatory status is justified in this case and not an acute inpatient admission.

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 admission is not substantiated.