Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis.

Treatment: Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission.

The denial is upheld. 

This is a female patient with a medical history of cholecystectomy who presented to the Emergency Room (ER) with complaints of lower abdominal pain and vomiting since the prior day and 3 episodes of diarrhea on the day of arrival. The patient complained of bilateral lower abdominal pain since the day prior and was sent from urgent care to rule out appendicitis. The patient was afebrile. The patient's abdominal exam revealed soft abdomen with diffused tenderness in the lower quadrants; non-distended. The plan was to admit for appendicitis. The patient's computed tomography (CT) scan of the abdomen revealed appendix thickened with augmented mucosal enhancement consistent with appendicitis. General surgery was consulted, and the patient continued to receive intravenous (IV) fluids and the pain was managed. The patient underwent an uneventful laparoscopic appendectomy. The operative note indicated that the patient's appendix was inflamed with turbid fluid in the peritoneal cavity. Pathology revealed acute suppurative appendicitis with periappendicitis. The postoperative course continued to be uneventful and the patient was discharged Postoperative (Post-op) day 1 with instructions to follow up with general surgery as an outpatient.

Based on the review of the medical record and literature, the acute inpatient admission was not medically necessary for this patient. The patient could have been cared for based upon an observation admission. The patient presented to the hospital after being sent from urgent care. The patient was taken to the Operating Room (OR) the next morning and was discharged on Post-op day 1, following an uneventful laparoscopic appendectomy. The patient did well postoperatively and had stable vital signs and was tolerating her diet. The patient's care could have been safely provided for under an observation status. The patient did not require an acute inpatient admission but rather observation status as she did not have any complications from the surgery that warranted an inpatient level of care. The patient could have been cared for with a 23-hour observation. The laparoscopic appendectomy was uneventful as there was no perforation or abscess noted. There was no evidence of a complicated postoperative course requiring hospitalization. Thus, the patient should have had the appendectomy performed not as acute inpatient admission but rather as a 23-hour observation status. 

The Milliman Care Guidelines for Appendectomy, without Abscess or Peritonitis, by Laparoscopy notes that 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. Based upon the records provided, this patient reached these milestones, and should have been discharged following observation within a 23-hour observation period. Furthermore, according to MCG, the goal length of stay is ambulatory. The patient did not have any co-morbidity that warranted inpatient admission. As per literature review, the standard for laparoscopic appendectomy, as in this case, is to be done as an observation status/ambulatory status.

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

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