Appeal type: Medical necessity
Decision: Upheld

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

This patient is a female child with no prior medical history who presented to the Emergency Department (ED) with complaints of worsening abdominal pain localizing to right lower quadrant (RLQ) and an episode of vomiting. As per the triage note, the patient presented with pain since the night before and denied fevers or diarrhea. The patient was afebrile. The patient's vital signs were stable, and exam revealed that the patient's abdomen was soft and non-distended with RLQ and left lower quadrant (LLQ) tenderness to palpation. The patient's pain was worse on the right side. An abdominal ultrasound revealed findings compatible with acute appendicitis with the appendix dilated up to 1 centimeter (cm) and non-compressible with associated thickening and hyperemia; no free fluid was identified. The patient's white blood cell (WBC) count was 14.32. The patient was admitted to Pediatrics and was made nothing-by-mouth (NPO) status and given intravenous (IV) antibiotics. The patient was taken to the Operating Room (OR) and underwent an uneventful laparoscopic appendectomy. There was no mention of perforation or abscess. Findings included dilated appendix with induration with some white fibrous exudate along most of its extent. Pathology report revealed acute appendicitis with transmural neutrophilic inflammation. The patient tolerated the procedure well. She was advanced on diet and was cleared for discharge later that day.

Based on the review of the records provided, the patient did not require acute, inpatient stay with hospital admission, as she could have been cared for based upon a 23-hour observation admission. The patient underwent an uneventful laparoscopic appendectomy and was discharged later that day. The patient did not need further acute care following the appendectomy except for the usual observation as noted. The patient did not have any clinical sign of an abscess or perforation at the time of surgery and did not have signs of generalized peritonitis. The patient was observed and discharged which all could have been done within a 23-hour observation period. Medical necessity of acute inpatient hospitalization was not warranted, as the patient was stable postoperatively. The patient was tolerating a diet and was discharged. There was no evidence of a complicated postoperative course requiring hospitalization. Therefore, the patient only required observation.

As per the MCG- Health Inpatient and Surgical Care 24th Edition Appendectomy, uncomplicated, open or laparoscopic ORG: P-20 (ISC) the Operative Status Criteria is ambulatory with the goal length of stay is ambulatory. 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) may be needed for: failure to achieve discharge status; prolonged fever and prolonged fever may require longer observation in hospital on parenteral antibiotics and one can expect brief stay extension; complicated appendicitis with discovery or development of generalized peritonitis or intra-abdominal abscess may require longer observation on parenteral antibiotics; complications such as wound infection, intra-abdominal abscess, fecal fistula, pylephlebitis, and intestinal obstruction may occur and require continued observation or reoperation and one can expect brief to moderate stay extension; prolonged ileus with prolonged ileus may delay initiation of feeding and one can expect brief stay extension; or postoperative bleeding may require reoperation and one can expect brief stay extension. However, in this case, none of these situations were seen as the patient had an uncomplicated non-perforated appendicitis as noted and did not have any complication post- surgery. The patient was tolerating diet and could have been cared for under an observation status (ambulatory setting). Therefore, inpatient admission was not medically necessary for this patient. 

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

Based on the above, the medical necessity for inpatient hospital admission is not substantiated. The insurer's denial should be upheld.