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.

According to the documentation submitted, this is a female child who was brought by ambulance to the Emergency Department (ED) for evaluation of abdominal pain, nausea and vomiting. The symptoms started the previous day; the pain was diffuse and had moved to the right lower quadrant (RLQ). On exam, the patient was febrile to 100.3 with RLQ tenderness without guarding or rebound. Labs included white blood cell (WBC) 18.2. Sonogram of the abdomen did not show evidence of acute appendicitis although the diagnosis could not be entirely excluded. Computed tomography (CT) of the abdomen revealed acute uncomplicated appendicitis. Intravenous (IV) Zosyn was administered. Surgery saw the patient and recommended admission to the pediatric service. 

Infectious Disease (ID) saw the patient because of generalized erythematous rash during Zosyn administration and to advise on antibiotic regimen. ID recommended Azactam, Flagyl, and IV Vancomycin and plan to de-escalate depending on operative findings.
The patient was taken to the operating room the following evening and underwent an uneventful laparoscopic (lap) appendectomy. 

Progress notes on the following post operative day indicate the patient was doing well without any abdominal pain or fever. She was started and tolerated a liquid diet.

ID saw the patient and noted the patient was afebrile and recommended sending her home on oral clindamycin and Levaquin until she was seen in follow up.

The patient did well as there were no post operative complications and the patient was discharged to home 2 days after admission tolerating a diet and pain well controlled.

Based upon the records provided the patient did not require acute inpatient admission as the patient should have been cared for based upon an observation admission. The patient was admitted to the hospital and was taken to surgery the following day. She underwent an uneventful lap appendectomy and was discharged the day after - all of which could have been done in an observation status. She did well post operatively(op) and had stable vital signs and was tolerating diet and could have been cared for under an observation status. The fact that she had an allergic reaction is not reason to justify an inpatient admission. She did not require an acute inpatient admission but rather observation status as she did not have any complications from the surgery that warranted inpatient care. The lap appendectomy was uneventful and there was no evidence of a perforation. There was no evidence of a complicated post op course requiring hospitalization. Thus, the patient should have had the appendectomy performed under an observation status without an inpatient admission. 

As per MCG (Milliman Care Guidelines)- Health Inpatient and Surgical Care 25th Edition Appendectomy, uncomplicated, open or laparoscopic ORG: P-20 (ISC) the Operative Status Criteria is ambulatory with the goal length of stay is ambulatory. 

To summarize, the inpatient 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 lap appendectomy- all of which could have been done in an observation status. 

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

The insurer's denial of coverage for inpatient hospital admission is upheld. Medical Necessity is not substantiated.