Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Appendicitis.
Treatment:  Inpatient hospital admission.

The insurer denied coverage for inpatient hospital admission.  The denial is upheld.

According to the documentation submitted, this is a case of a teenager who presented to the emergency department (ED) complaining of abdominal pain for the past 2-3 months. Pelvic Ultrasound revealed 2.7 centimeters (cm) right ovarian cyst versus dominant follicle. Ultrasound of the appendix revealed minimally distended appendix with hyperemia and non-compressibility, but no free fluid identified. The findings were suspicious for acute appendicitis. Computed Tomography of the abdomen was equivocal for acute appendicitis. White blood cell count (WBC) was 7.38. The plan was to admit to surgery for surgical intervention and to give Ceftriaxone and Flagyl. 

A laparoscopic appendectomy and rectus sheath block were done the day after admisison. The finding included an appendix that did not appear acutely inflamed. The appendix however was removed. There was no abscess or perforation noted in the report. Path revealed appendix without significant histopathologic findings. The brief operative notes also confirmed that the appendix was normal. The patient did well postoperatively and was discharged the same day. 

As per Milliman Care Guidelines (MCG)- Health Inpatient and Surgical Care 27th Edition Appendectomy, uncomplicated, open or laparoscopic ORG: P-20 (ISC) 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. The patient was tolerating diet and should have been cared for under an observation status (ambulatory setting). This patient did not have any factors that required hospitalization. 

Furthermore, MCG also noted: Analysis of 1441 pediatric patients undergoing laparoscopic appendectomy for uncomplicated appendicitis reported 35% with same-day discharge and 65% discharged after overnight observation. Analysis of procedure data for a large commercially insured pediatric population shows 89% of laparoscopic appendectomies for acute appendicitis without peritonitis or abscess are performed on an outpatient basis." There is justification that this patient should have had the procedure in an observation setting and not an acute inpatient admission. 

Finally, MCG Health noted in General recovery care 27th edition Pediatric General admission criteria GRG: CG-PAC (ISC GRG)  that admission is indicated for 1 or more of the following: Hemodynamic instability; Cardiac arrhythmias of immediate concern; Severe heart failure in child; Severe respiratory findings; Neurologic abnormalities; Abdominal abnormalities; Acute kidney injury (stage 2); Acute renal failure (stage 3 acute kidney injury); Significant uremic complications; Infant 29 days to 90 days of age with temperature of 100.4 degrees Fahrenheit (F) (38 degrees Celsius (C)) or greater and; Child 3 months to 3 years of age with temperature of 102.2 degrees F (39 degrees C) or greater and Febrile seizure and High fever or other high-risk infection situation in child. The patient did not meet the criteria to necessitate acute inpatient admission but rather observation. 

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 hospital admission is not substantiated.