Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis
Treatment: Inpatient hospital admission
The insurer denied coverage for inpatient hospital admission.
The denial is upheld.

According to the documentation submitted, this is an adult patient who presented to the emergency department (ED) with a chief complaint of abdominal pain for two days. The patient denied fevers, chills, or vomiting. The patient did report diarrhea intermittently over the past 2 days. As per the ED provider note, the patient had abdominal tenderness in the Right Lower Quadrant (RLQ) and Left Lower Quadrant (LLQ). The patient was afebrile. The white blood cell (WBC) count was 8.2. Computed Tomography (CT) revealed findings suggestive of mild early acute appendicitis with mucosal wall thickening up to 12 millimeters (mm) without significant surrounding inflammation or fat stranding or abscess collection. There was also diffuse colitis changes noted with suggestion of gastroenteritis. Antibiotics were ordered as per surgery.

The patient was taken to the operating room for a laparoscopic (lap) appendectomy. The findings were an early long acutely inflamed appendix. Pathology revealed an appendix with acute inflammation involving the mucosa and inflammatory exudates present within the lumen. 

MCG (Milliman Care Guidelines) Health noted in General recovery care 27th edition General admission criteria General Recovery Guidelines (GRG): CG-GAC (ISC GRG) that admission is indicated for 1 or more of the following: hemodynamic instability, acute cardiac or peripheral ischemia, cardiac arrhythmias of immediate concern, severe respiratory findings, severe airflow or ventilation abnormalities, anasarca, neurologic abnormalities, altered mental status that is severe or persistent, physiologic disorder (such as acute acidosis, thyroid storm, adrenal crisis) that is severe or persists despite observation care, suspicion for or diagnosis of abdominal catastrophe, temperature less than 95 degrees Fahrenheit (35 degrees Celsius) (rectal), severe electrolyte abnormalities requiring inpatient care, severe anemia, high-risk low platelet count, disseminated intravascular coagulation, adverse drug or systemic toxin reaction that is severe or persists despite observation, severe pain requiring acute inpatient management, inpatient monitoring needed, treatment requiring inpatient care, emergency procedures needed. Based upon these guidelines, this patient should have been observed rather than placed in an acute admission as the patient did not have any indication as noted above for inpatient stay or prolonged stay. The patient had a non-perforated appendicitis and underwent an uneventful lap appendectomy and this is an ambulatory procedure as the insurer noted.

To summarize, the reviewer agrees that the inpatient hospital admission was not medically necessary at the acute inpatient level and denial for hospital admission should be upheld. The patient was admitted and underwent an uneventful laparoscopic appendectomy which could have been done in an observation status. The reviewer does believe that based upon these findings the health care plan did act reasonably and with sound medical judgment. Finally, the reviewer is knowledgeable in this condition and the recommended health care services provided for this condition and therefore agrees that the medical necessity of the inpatient hospital admission was not justified, as observation status was sufficient. The criteria the reviewer has utilized included own personal experience as to what constitutes good acceptable standard of care and MCG guidelines and references below. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably, with sound medical judgment, and in the best interest of the patient. 

The medical necessity for the inpatient hospital admission is not substantiated.