Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 


According to the documentation submitted, this is a patient with no past medical history (PMHX) who presented to the emergency department (ED).  As per the triage note the patient presented to the ED with complaint of abdominal pain for 3 days associated with 2 episodes of vomiting. The patient was afebrile with stable vital signs. As per the ED provider note the patient presented with right lower quadrant (RLQ) abdominal pain which had been progressive over the previous 2 days with nausea and subjective fevers. Exam revealed RLQ tenderness on palpation with guarding and rebound.  White blood cell count (WBC) 13.54. The assessment was acute appendicitis with computed tomography (CT) confirming acute appendicitis. 

The patient was admitted and received Zosyn. Surgery was made aware and saw the patient and noted the patient was to be put on the operating room schedule. The patient was taken to the operating room for an uncomplicated lap appendectomy. Upon entering the abdomen, it was noted that they had created an enterotomy without spillage into the peritoneal cavity. This was repaired primarily. The appendix was noted to be purulent. There was no perforation otherwise noted. Pathology revealed supportive appendicitis with peri appendicitis.

Post-op the plan was to finish the post-op antibiotics and observe patient.

Progress notes indicated the patient was doing well without complaints. The patient was tolerating liquids and no fever noted. The attending saw the patient the patient was doing okay with a benign abdomen.  The plan was to discharge home after lunch. As per the attending note the patient was discharged and to follow-up in their office for staple removal.

Based upon the records provided for review, the patient did not require acute inpatient admission since they should have been managed in an observation status. The patient did not require an acute inpatient admission but rather observation status as they did not have any complications from the surgery that warranted inpatient care. The lap appendectomy was uneventful and there was no perforation. The enterotomy was not a reason for the patient to be inpatient. There was no evidence of a complicated post op course requiring hospitalization and the patient was discharged within 23 hours (on the same day of surgery). Thus, the patient should have had the appendectomy performed under an observation status without acute inpatient admission. 

To summarize, the reviewer feels that the inpatient admission was not medically necessary at the acute inpatient level and denial for hospital admission should be upheld. The patient was admitted and underwent an uneventful lap appendectomy - all of which should have been done in an observation status. The reviewer does believe that based upon these findings the health care plan did act reasonably and with sound medical judgment.  Finally, the reviewer is knowledgeable in this condition and the recommended health care services provided for this condition and therefore feel that the medical necessity of the inpatient admission was not justified, as observation status was sufficient. 

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.