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 who presented to the emergency department (ED) with right lower quadrant (RLQ) pain for 2 days; he denied nausea, vomiting and fever. Examination revealed abdominal tenderness in the RLQ without rebound or guarding. He was afebrile. The impression was acute appendicitis. The plan was surgery consultation, admission and antibiotics.

Surgical history and physical noted the history of coronary artery bypass graft (CABG) and 2-day history of abdominal pain in the RLQ. It was also noted the patient was admitted in the past for chest pain and had a normal echo, stress test, carotid duplex and troponins and was cleared by cardiology. He was afebrile and had focal tenderness at McBurney's point without rebound or guarding. White blood cell (WBC) count was 9.43. Computed tomography (CT) revealed acute appendicitis without abscess. The plan was cardiology clearance and operative planning. Cardiology saw the patient, noted the prior cardiac studies and cleared the patient for surgery.

The patient underwent an uneventful laparoscopic appendectomy. Pathology revealed acute appendicitis. The patient did well postoperatively and was stable, tolerating liquid and voiding freely.

Progress note indicated the patient was started on Flomax for urinary hesitancy. His diet was advanced. He was afebrile and denied nausea or vomiting. He was voiding normally and was cleared for discharge.

Based upon the records the patient did not require acute inpatient admission. The laparoscopic appendectomy was uneventful, and this was a non-perforated appendicitis. There was no evidence of a complicated post operative course requiring hospitalization. 

According to Milliman Care Guidelines (MCG) Health Inpatient and Surgical Care 27th Edition Appendectomy, without Abscess or Peritonitis, by laparoscopy, 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 operative Status Criteria is ambulatory.  

In addition, MCG also notes that: "A study of 376 adult patients (mean age 35 years) who underwent laparoscopic appendectomy for uncomplicated appendicitis found that 80% were managed on an outpatient basis. Analysis of 563 adult patients (mean age 36 years) who underwent laparoscopic appendectomy for uncomplicated appendicitis found that 86% were treated on an outpatient basis. A cohort of 871 adults (mean age 35 years) with uncomplicated appendicitis who underwent laparoscopic appendectomy had a mean length of stay of 17.5 hours. Analysis of procedure data for a large commercially insured adult population shows 88% of laparoscopic appendectomies performed on patients with appendicitis without peritonitis or abscess being performed on an outpatient basis. Analysis of procedure data for a Medicare population shows 72% of laparoscopic appendectomies performed on patients with appendicitis without peritonitis or abscess being performed on an outpatient basis." 

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.