Appeal type: Medical necessity
Decision: Upheld

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

The patient is a young child with no past medical history who presented with worsening right lower quadrant pain which began the evening prior to admission. The pain was worsened with walking or bending over. Vital signs were stable upon presentation to the emergency department, with a blood pressure of 114/71, heart rate of 123, respiratory rate of 22, temperature of 99.6 Fahrenheit, an oxygen saturation of 98% (percent) on room air. White blood cell count was elevated at 16.66, with a hemoglobin of 12.2 and platelet count of 371. Physical examination revealed tenderness in the right lower quadrant. Ultrasound of the abdomen was performed, demonstrating a mildly distended, fluid-filled appendix measuring up to 8 millimeter (mm) with minimal compressibility and localized hyperemia indicative of acute appendicitis. The patient received intravenous (IV) Ceftriaxone 1550 milligram (mg) and IV Flagyl 310 mg. She was transferred where she was evaluated by surgery. Intravenous fluids and antibiotics were continued, and the patient underwent a laparoscopic appendectomy for acute appendicitis without perforation or abscess. The patient did well following the surgery and was discharged to home. 

There is extensive literature concerning outpatient laparoscopic appendectomy for acute appendicitis. In an earlier study, Cash et al. performed a retrospective review of 119 patients undergoing laparoscopic appendectomy for uncomplicated acute appendicitis. There were no significant differences in patient age, gender, and preoperative comorbidities. Postoperative complications (including superficial wound infections, urinary retention, urinary tract infection, intra-abdominal bleeding, pneumonia, and infected hematoma) occurred in 2.4% of outpatients and 11.7% of inpatients. They concluded that outpatient laparoscopic appendectomy can be performed safely in selected patients with significant cost savings. Despite this study, however, national data reflected that the majority of laparoscopic appendectomies are performed with overnight admission.

The patient was admitted as an inpatient for acute appendicitis and underwent a laparoscopic appendectomy.  The patient did not require an inpatient admission for acute appendicitis. She had no evidence of fever, tachycardia, or medical instability. There was no evidence of a post-operative complication that would require close monitoring or further treatment. The patient did not have any serious co-morbid conditions requiring close observation. The appendix was not gangrenous or perforated, and there was no evidence of an abscess that would require prolonged IV antibiotic therapy. Therefore, the medical necessity for the inpatient admission of the patient has not been established. The care that was received could safely and effectively have been performed on an outpatient basis. The health plan acted reasonably and with sound medical judgement and in the best interest of the patient. 

The insurer's denial of coverage for inpatient hospital admission is upheld. Medical necessity is not substantiated.