Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute Appendicitis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned 

The patient is a female patient with a medical history of asthma who presented to the Emergency Department (ED) complaining of right-sided abdominal pain for approximately 1 week.  The submitted documentation indicated that this patient's right lower quadrant pain radiates to the back.  The physical examination revealed abdominal tenderness to the right lower quadrant.  There is right costovertebral angle (CVA) tenderness.  The physician detailed that the patient presented initially with right lower quadrant pain and therefore, it was recommended that the patient be evaluated for appendicitis versus kidney stone.  The recommendation was made for laboratory and diagnostic studies.  The submitted documentation indicated that the patient had trace ketones and protein in her urine.  However, the laboratory studies did not reveal any significant findings.  The submitted documentation indicates that the imaging revealed a dilated appendix with periappendiceal fat stranding compatible with acute appendicitis and periappendiceal abscess.  The recommendation was made to admit the patient for general surgery services.  The patient underwent a laparoscopic appendectomy with extensive laparoscopic lysis of adhesions and drainage of pelvic abscess.  The patient underwent the procedure without complication and postoperatively, the patient was managed with continued intravenous (IV) fluids and medication.  The patient was able to advance her diet, and there was no postoperative complication.  

Based on the review of the medical record and literature, inpatient admission was medically necessary for this patient. This patient presented with appendicitis with peri-appendiceal abscess consistent with perforated appendicitis.  This patient had a complicated appendicitis that required intravenous (IV) antibiotics and surgical intervention. Intra-operatively, the patient was found to have intra-abdominal abscess and a perforated appendix.  As per operative notes, a Jackson-Pratt (JP) drain was placed in the abscess cavity.  Postoperatively, the patient was treated with intravenous (IV) antibiotics, and was subsequently discharged. 

Many studies show that patients with complicated appendicitis, which includes patients with appendicitis with abscess, received post-operative antibiotics for 3 to 5 days.  Patients who undergo appendectomy and are discharged on the same day are patients with uncomplicated appendicitis.  In this case, this patient had a complicated appendicitis. The patient's hospital stay following surgery is justified as she was receiving intravenous (IV) antibiotics, which is the standard of care for patients with an intra-abdominal infection, such as complicated appendicitis.  

Therefore, based on this patient's clinical presentation and objective findings, the inpatient admission was medically necessary for this patient.  

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient. 

Based on the above, the medical necessity for the inpatient admission is substantiated. The insurer's denial should be overturned.