Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Appendicitis
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

This is a male patient who presented to the emergency department with abdominal pain. His evaluation included a physical exam, labs, and an abdominal computed tomography (CT) scan. The white blood cell count (WBC) count was elevated at 15.4 thousand (K). The CT scan showed appendicitis with marked inflammation of the surrounding fat. His evaluation yielded the diagnosis of acute appendicitis. His presurgical vital signs were normal.

The patient underwent a laparoscopic appendectomy. The operative notes and the anesthetic record indicate findings of a retrocecal appendicitis with purulent fluid in the lower abdomen. A drain was placed at the time of surgery. On the first post-surgical day, he was treated with continued intravenous (IV) antibiotics. The surgical drain had serosanguinous fluid in the bulb.  He was provided continued IV perioperative antibiotics and the drain was kept in place. The WBC count was 11.3 K. He was without a fever and was determined to be clinically stable for discharge from the hospital with the drain kept in place. He was discharged home. The pathology report documents the diagnosis of acute appendicitis, focally gangrenous with perforation. At issue is the medical necessity of an inpatient stay.

YAcute inpatient admission was medically necessary for this patient because the patient had a perforated appendicitis that was appropriately treated with an appendectomy, drain placement and continued provision of parenteral antibiotics in the post-surgical period. In this case the patient presented with a complicated appendicitis that was perforated. It was reasonably anticipated that his inpatient needs would span a period of greater than 48-hours. Continued inpatient care was consistent with the Milliman Care Guidelines (MCG) and with generally accepted standards of care. Discharge prior to resolution of septic manifestations (leukocytosis) would have potentially compromised this patient's health.

He was treated with a timely appendectomy and parenteral antibiotic therapy was continued in the post-surgical period. This patient's persistent leukocytosis mandated continued inpatient care and clinical follow up with monitoring and lab assessment. Once the patient demonstrated normal vital signs, tolerance of diet, and drain management, he was appropriately discharged from the hospital. The care and treatment provided in this case was most appropriately provided with an acute inpatient admission.
The Milliman Care Guidelines (MCG) state that inpatient admission with the goal length of stay of 2-days is indicated in the setting of a perforated appendicitis. Extended stay may be needed for complications, continued ileus, postoperative bleeding, or comorbidities. This patient presented to the hospital with a perforated appendicitis. He underwent urgent surgery, drain placement, and was provided IV antibiotics in the post-surgical period. Based on his presenting condition, pre-operative imaging, and surgical findings of perforated appendicitis, it was reasonably anticipated that the necessary care would span a period of greater than 48-hours. This was consistent with an inpatient stay.