Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute appendicitis 

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission. The denial is upheld. 

This patient is a female with no past medical history but with a surgical history of C section who presented to the emergency department (ED) with complaints of abdominal pain. She was afebrile with diffuse tenderness across the lower abdomen. WBC was 8.91. CT of the abdomen revealed acute appendicitis without gross perforation. As per a note, the patient would receive Unasyn and be allowed to eat a regular diet and be admitted to surgery for further management.

Progress note indicated that there were no acute events overnight and that the patient reported mild improvement in her abdominal pain. There was no nausea or vomiting. The patient feels like she could tolerate a diet and the patient denies fever. The note indicated the patient was on IV Unasyn with some improvement. The attending noted that the patient was doing well and clinically tolerating a regular diet. The plan was to discharge to home on Augmentin for 7 days. Based upon the records provided, the patient did not require an acute level of care as the patient could have been cared for based upon an observation admission. The patient presented to the hospital and despite the fact that the CT showed acute appendicitis she was treated conservatively with antibiotics. The patient decided not to undergo surgery and was feeling better on the day after presentation and was discharged later that day. Thus, she could have been called for on an observation status.

According to MCG Inpatient and Surgical Care 23rd Edition Abdominal Pain, Undiagnosed ORG: M-05 (ISC) admission may be indicated for 1 or more of the following: Surgery needed that cannot be performed on ambulatory basis; Peritoneal signs present ; Evaluation requires patient to not eat or drink for extended period (e.g., more than 24 hours; Hemodynamic instability; Severe pain requiring acute inpatient management; Identification of etiology or finding that requires inpatient care (e.g., aortic dissection, free air, bowel ischemia, visceral organ torsion; Signs of intestinal obstruction; Suspected toxic megacolon; Bacteremia; Severe electrolyte abnormalities requiring inpatient care; Inability to maintain oral hydration 
(e.g. needs IV fluid support) that persists after emergency department and observation are treatment; Percutaneous or open drainage (e.g., abscess, biliary tract) procedures; Parenteral nutrition regimen that must be implemented on inpatient basis; Other condition, treatment, or monitoring requiring inpatient admission.

Even if one was to say that the patient was to have an appendectomy at time of this admission, this in itself is not an indication for an acute admission as appendectomy can be done in an observation/ambulatory status. As noted by MCG guidelines, Inpatient and Surgical Care 23nd Edition; Appendectomy, without Peritonitis, by Laparoscopy ORG: S-175 (ISC) optimal recovery course includes floor to discharge with the following milestones completed: procedure completed; no evidence of ileus or bowel obstruction; fever absent; diet tolerated; pain absent or managed, oral medications and oral diet.

To summarize, inpatient admission was not medically necessary at the acute care level. The health care plan did act reasonably and with sound medical judgment.  

Based on the above, the medical necessity for the inpatient admission is not substantiated.  The insurer's denial is upheld.