Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a man. His medical and surgical histories were negative. He presented to an emergency room with a one-day history of right-lower-quadrant abdominal pain, nausea, vomiting, and diarrhea.

The patient's vital signs were as follows: Temperature 98.6, pulse 96, blood pressure 130/95, respirations 16, and oxygenation 98% on room air. Physical examination demonstrated tenderness-to-palpation of the right-lower-quadrant of the abdomen. Serum laboratories demonstrated a normal white-blood-cell count of 9.85. PCR (polymerase chain reaction) demonstrated infection with COVID-19. Computed tomography demonstrated acute appendicitis.

The patient was admitted at an acute inpatient level-of-care for a diagnosis of acute appendicitis. He was made nil per os [NPO]; and provided with intravenous fluids, antibiotics, and analgesics. The patient underwent laparoscopic appendectomy. Surgery and recovery were uncomplicated.

The patient was discharged home in good and stable condition with prescriptions for oral analgesics and stool-softeners; with instructions for COVID-19-associated isolation, social-distancing, and mask-wearing; and with outpatient surgical follow-up.

No, the Inpatient admission was not medically necessary.

According to several studies, the majority of patients with uncomplicated appendicitis who undergo laparoscopic appendectomy can be treated effectively and safely on outpatient or observational status [Gilliam et al; Cross et al; Cosse et al]. In fact, most patients can be discharged from the post-anesthesia care unit (the recovery room) [Mitchell et al; Dubois et al; Cash et al]. Therefore, for this patient, there was no need for admission at an acute inpatient level-of-care; he could have been treated at a lower level-of-care.

Moreover, while the patient was diagnosed with COVID-19, he did not demonstrate significant co-morbidities or physiologic derangements to warrant admission at an acute inpatient level-of-care. In fact, according to an international review published by The Lancet, the major risk factor for mortality for patients with COVID-19 infection undergoing surgery was age old enough[Nepogodiev]. This patient did not meet this risk factor.

Additionally, according to an appeals letter, there was concern over "post-op mayhem potential." However, if this were truly the case, then the patient's providers had the option of pursuing non-operative management in accordance with guidelines from the American College of Surgeons -- "Based on the surgeon's judgment, patient preferences, and local resources (e.g., hospital staff, bed, and PPE [personal protective equipment] supply availability) antibiotics are an acceptable first-line treatment, with appendectomy offered for those with worsening or recurrent symptoms." [ACS]. This approach could have avoided admission and would have avoided "post-op mayhem potential."

Patients with uncomplicated appendicitis who undergo laparoscopic appendectomy can be treated effectively and safely on outpatient or observational status; most patients can be discharged from the recovery room. The patient did not require admission at an acute inpatient level-of-care; he could have been treated at a lower level-of-care.