Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is Upheld

This patient is a previously healthy adult male who presented to the emergency department with the complaint of abdominal pain and vomiting. His examination revealed abdominal tenderness in 
the right lower abdomen. Vital signs identified a normal temperature at the time of presentation. The heart rate was 63 beats per minute. The white blood cell (WBC) count was elevated at 18.3 thousand (K). Abdominal computed tomography (CT) scan was completed showing findings consistent with acute appendicitis. The patient was admitted to the hospital and was started on intravenous (IV) antibiotics. Surgical consultation was obtained. On day #2 the patient underwent laparoscopic appendectomy. Operative findings included an acutely inflamed appendix. The operation was completed without complication. The patient was monitored following surgery and remained stable. The post-surgical note indicates that the patient was without new complaint. He had normal vital signs following surgery. He was started on a diet following surgery. He was discharged from the hospital on day #2 following the initial surgical recovery with instructions for surgical follow. The health plan rationale for denial is that there is no documentation of need for an inpatient level of care and the care rendered could have been provided without full admission to the hospital. The care provided could have been rendered without an inpatient status. This letter references the Milliman Care Guidelines (MCG) criteria.

Inpatient care was not medically necessary for this patient.

The health plan rationale for denial is that there is no documentation of need for an inpatient level of care and the care rendered could have been provided without full admission to the hospital. The submitted medical records do not indicate that there were hemodynamic, pulmonary, neurological, or metabolic reasons for an acute inpatient level of care. Vital signs were normal at the time of emergency department presentation. There were not complications of surgery performed the next day and this operation is typically performed without need for full inpatient admission. Inpatient care for this patient was not medically necessary based on the standard of care. The care provided during this time could have reasonably and appropriately been provided with a lower level of care. A lower level of care would have provided for emergency department assessment, provision of intravenous fluid and antibiotics, surgical consultation, 
surgery to remove the appendix and post-surgical monitoring. This patient was clinically stable at the time of presentation to the emergency department, he remained stable throughout the perioperative period and was able to be discharged from the hospital following an uncomplicated initial recovery.
Generally accepted medical standards indicate that in the absence of hemodynamic instability, sepsis or toxicity, significant electrolyte imbalance, bleeding, gastrointestinal obstruction or 
surgical complications, treatment as provided in this case could be provided without an inpatient level of care. In this case the patient tolerated oral hydration following surgery. A lower level of care would have appropriately provided for treatment and overnight monitoring. Inpatient care was not required or medically necessary in this case per generally accepted medical standards.