Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute Appendicitis. 
Treatment: Inpatient Admission. 

The insurer denied coverage for inpatient admission. 

The denial is upheld. 

According to the documentation submitted, this patient with a past medical history of anemia was admitted. The triage nurse noted the patient was transferred from another hospital with complaints of abdominal pain. As per the hospital emergency department (ED) note, the patient presented to the hospital with headache and chest pain. She denied fevers. On exam she had abdominal tenderness. She has a family history of brain aneurysm. White blood cell count (WBC) was 19.2. computed tomography (CT) of the head and computerized tomography angiography (CTA) of the brain was unremarkable. CT of the abdomen showed a distended linear structure in the region of the appendix and thickening with recommendation for clinical correlation for appendicitis. The patient was transferred for evaluation for questionable appendicitis. As per the ED triage note, the patient has a urinary tract infection (UTI) and received Zosyn. She was febrile with stable vital signs. As per the ED provider note, the patient had no significant past history and presented from outside hospital after a bilateral temporal headache, positional blurry vision, mid lower chest pain and nausea. The patient's father had a cerebral aneurysm. At the outside hospital CT of the head and CT angio, and chest x-rays revealed (CXR) were negative. CT of the abdomen revealed 1.3 liner image in the area of the appendix with some enlarged lymph nodes and moderate stool burden. Urinalysis (UA) showed leukocytes. The patient had 1 episode of emesis. Exam revealed left lower quadrant (LLQ) and flank tenderness WBC was 17.33. Ultrasound of the appendix revealed non compressible dilated appendix measuring up to 1.4 cm (centimeters). The findings were suspicious for early acute appendicitis. The patient was admitted to pediatrics surgical team with the plan for laparoscopic (lap) appendectomy. 

She underwent an uneventful lap appendectomy with the findings of a non-perforated acute appendicitis. The patient did well and was discharged later in the day from ambulatory surgical unit (ASU)/Post anesthesia care unit (PACU) with follow up as an outpatient. 

The patient did not require acute inpatient admission as the patient could have been cared for based upon an observation admission. 

As per MCG (Milliman Care Guidelines)- Health Inpatient and Surgical Care 26th Edition Appendectomy, uncomplicated, open or laparoscopic 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 conversion to an open procedure or longer observation on parenteral antibiotics; The patient did not have any co morbidities that required treatment at the time that would have extended her stay. The patient should have had the procedure done under ambulatory/observation status as she did not require an acute inpatient setting. 

The patient did not meet the criteria to necessitate acute inpatient admission but rather observation. Based upon these guidelines this patient could have been observed rather than an acute admission as she did not have any indication as noted above for inpatient stay but rather observation/ambulatory status. 

The patient was admitted and underwent an uneventful lap appendectomy- all of which could have been done in an observation status. She did not need an acute admission. 

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

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