Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute appendicitis. 
Treatment: Inpatient admission. 

The insurer denied coverage for the inpatient admission. 

The denial is upheld. 

This is a male patient with no significant past medical history who presented to the Emergency Room (ER) with complaints of right lower quadrant (RLQ) abdominal pain. The patient was triaged for abdominal pain, intermittent for 1 week that is worsening with nausea, vomiting, diarrhea. As per the Emergency Department (ED) provider note, on exam the patient had RLQ tenderness with guarding. The patient was given piperacillin intravenous (IV) q8h [every eight hours]. Computed Tomography (CT) of the abdomen showed severe acute appendicitis with no free air or evidence of abscess noted. The impression was acute appendicitis with localized peritonitis without perforation, abscess or gangrene. The patient reportedly had acute appendicitis and was awaiting surgical consultation. The patient was admitted as an inpatient. 

Based upon the records provided, the patient did not require acute inpatient admission as he should have been cared for based upon an observation admission. The patient's care could have been done in an observation setting. He did not undergo any surgery and if he had undergone appendectomy, this in itself is considered ambulatory. It was noted on the CT that there was no perforation or abscess noted. He had stable vital signs and he was afebrile. His white blood cell (WBC) count was only slightly elevated. He could have been cared for under an observation status. 

Based upon the guidelines of Milliman Care Guidelines (MCG) Health General Recovery Care, 24th edition, General Admission Criteria, this patient could have been observed rather than an acute admission. He did not have sign of sepsis. He had appendicitis and was medically managed with IV antibiotics and improved fairly rapidly such that his diet was advanced to a regular diet and he was able to be discharged the following day on oral antibiotics. 

Furthermore, if this patient had undergone an appendectomy, it would have been done under an observation/ambulatory status. As noted by MCG Health Inpatient and Surgical Care, 24th Edition, Appendectomy, without Abscess or Peritonitis, by Laparoscopy, optimal recovery course includes floor to discharge with the following milestones completed: hemodynamic stability; successfully uncomplicated lap appendectomy; no evidence of post op or surgical site infection; diet tolerated; pain absent or managed; no evidence of ileus or bowel obstruction; oral medications and oral diet. Furthermore, according to MCG, the goal length of stay is ambulatory. Thus, if the patient had undergone an appendectomy, the goal length of stay would have been ambulatory as he did not have any comorbidities that warranted inpatient admission. 

The inpatient admission stay was not medically necessary at the acute inpatient level, and denial for hospital admission should be upheld. 

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

The carrier's denial of coverage for the inpatient admission is upheld. The medical necessity is not substantiated.