Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Appendicitis.
Treatment:  Inpatient Hospital Admission.

The insurer denied the inpatient hospital admission.  The health plan's determination is upheld.

The patient is a female who presented to the emergency department (ED) with the complaint of abdominal pain. She was evaluated with examinations, laboratory studies, and imaging. This assessment revealed right lower abdominal tenderness and ultrasound findings of acute appendicitis. Her vital signs identified tachycardia (heart rate of 120 beats per minute) at the time of presentation. The white blood cell (WBC) count was elevated to 18.6. A surgical consultation was obtained. The patient was admitted to the hospital and started on intravenous (IV) antibiotics. The patient underwent surgical treatment for acute appendicitis (laparoscopic appendectomy).

The diet was advanced and pain management was with oral medications following surgery. Her vital signs remained stable during the period of monitoring. She was discharged from the hospital with instructions for surgical follow up.

The health plan rationale for denial is that there was no documentation of need for an inpatient level of care. The patient presented to the ED and underwent removal of the appendix. The care provided could have been rendered with an observation level of care (rather than inpatient level of care). This letter references Milliman Care Guidelines (MCG).

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

The acute inpatient hospitalization was not medically necessary for this patient. The medical records support that this patient could have been reasonably and safely monitored and treated at an alternate level of care without the need for a full inpatient admission.

This patient presented to the ED with abdominal pain. The evaluation with examinations, laboratory data, and an abdominal ultrasound supported the diagnosis of acute appendicitis. The diagnosis and indication for surgery was established on the day of admission. The patient was treated with IV antibiotics and a laparoscopic appendectomy on the following day. Following surgery, she was clinically stable and was tolerating a diet. She was discharged from the hospital with instructions for surgical follow up.

The patient was clinically stable at the time of presentation and remained so during the course of care. An alternate level of care designation would have provided for surgical assessment and provision of antibiotics. The alternate level of care would have also allowed for overnight monitoring (if needed).

Generally accepted criteria indicate that in the absence of hemodynamic instability, sepsis or toxicity, significant electrolyte imbalance, bleeding, gastrointestinal (GI) obstruction, or surgical complications, the treatment of appendicitis may be provided without an inpatient admission. In this case, the patient tolerated oral hydration, diet, and medication, and her pain was well controlled. An alternate level of care would have appropriately provided for surgical assessment, provision of antibiotics, and appendectomy, as was provided in this case. Inpatient care was not required or medically necessary in this case per generally accepted medical standards.

The health plan's determination of medical necessity is upheld in whole.