Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute appendicitis.

Treatment: Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission

The denial is upheld. 

This is a female patient with no significant past medical history and a surgical history of an abdominoplasty who  presented to the Emergency Department (ED) with complaints of generalized abdominal pan with vomiting that started that day. The patient was admitted. The patient was afebrile with stable vital signs. As per the ED provider note, the patient complained of abdominal pain, nausea and vomiting since the prior night. The principal diagnosis was acute appendicitis, and the plan was to admit to surgery. Surgical history and physical confirmed pain localized to the lower abdomen, sharp non-radiating with nausea and vomiting. Computed Tomography (CT) scan of the abdomen revealed a dilated appendix suspicious for acute appendicitis. White Blood Cell (WBC) count was 14.94. Medical clearance was obtained prior to surgery. The patient was taken to the operating room for a laparoscopic (lap) appendectomy. The operative report indicated the patient underwent an uneventful lap appendectomy. The operative findings included dilated and inflamed appendix. She tolerated the procedure and was transferred to the post anesthesia care unit (PACU) in stable condition. She did well and was discharged to the floor. Magnetic Resonance of the abdomen revealed no evidence of hepatic vein thrombosis. A progress note indicated the patient tolerated the diet and had pain control. The patient was discharged to home with outpatient instructions to follow up with surgery.

Based upon the records provided the patient did not require acute inpatient admission as the patient should have been cared for based upon an observation admission. The patient presented to the hospital and was taken to the surgery on the same day. She underwent an uneventful laparoscopic appendectomy and was discharged the following day- all of which could have been done in an observation status. She did well post operatively and had stable vital signs and was tolerating diet and could have been cared for under an observation status. She did not require an acute inpatient admission but rather observation status as she did not have any complications from the surgery that warranted inpatient care. The laparoscopic appendectomy was uneventful and there was no perforation or purulent fluid/ abscess. There was no evidence of a complicated post-operative course requiring hospitalization. Thus, the patient could have had the appendectomy performed under an observation status without an inpatient admission. 

Based upon Milliman Care Guidelines (MCG) Health Inpatient and Surgical Care 25th Edition Appendectomy, without Abscess or Peritonitis, by laparoscopy, the patient did not have any comorbidity that required treatment at the time that would have extended her stay. The procedure is ambulatory. In addition, based on MCG Health General Recovery care 25th edition General admission criteria, admission was not warranted. Based upon these guidelines this patient could have been observed rather than an acute admission. She did not have an elevated temperature. She did not have signs of sepsis. She had appendicitis and underwent an uneventful laparoscopic appendectomy, and she was able to be discharged the following day on oral antibiotics.

The health care plan did act reasonably and with sound medical judgment.  

The medical necessity for the inpatient hospital admission is not substantiated. The insurer's denial is upheld.