Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain, Appendicitis, s/p (status post) Appendectomy
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient hospital stay.
The health plan's determination is upheld.

The patient is a male who presented to the emergency department (ED) with the complaint of abdominal pain of 1-week duration. An examination revealed right lower abdominal tenderness. His vital signs were normal at the time of presentation. The white blood cell count (WBC) was elevated at 12.7 thousand(K). A surgical consultation was obtained. A computed tomography (CT) scan was completed showing findings of acute appendicitis. The patient was started on intravenous (IV) antibiotics. The patient underwent a laparoscopy with an appendectomy for the condition of appendicitis. The operative dictation describes a severely inflamed and suppurative appendix.

Following surgery, the patient was treated with IV fluids, antibiotics, and analgesia. His vital signs were consistently normal in the perioperative period. The day after surgery he was without complaint. His WBC count had normalized to 9.1 K. He was transitioned to oral medications and a regular diet.

The health plan rationale for denial is that the patient underwent an uncomplicated appendectomy. The denial letter states that there was no documentation of need for an inpatient level of care. This letter references Milliman Care Guidelines (MCG) for an Appendectomy without abscess or peritonitis by laparoscopy.

The health plan, in its determination of medical necessity acted reasonably, with sound medical judgment and in the best interest of the patient. An acute inpatient hospitalization was not medically necessary for the patient, this is supported by the medical records. 

The requested health service/treatment of an Inpatient Hospital Admission was not medically necessary for the patient. The care and treatment provided could have appropriately been rendered at an alternate level of care. The patient presented with abdominal pain. The evaluation with examination, laboratory data, and CT scan supported the diagnosis of acute appendicitis. He underwent an uncomplicated appendectomy. The day after surgery his vital signs and laboratory data were normal. He was tolerating a diet. His pain medications were transitioned to oral medications. He was maintained on parenteral antibiotics (Zosyn). He was discharged from the hospital two days after surgery.
The patient was clinically stable at the time of presentation and remained so during the course of care. An alternate level of care designation would have provided for a presurgical assessment, operative treatment and post-surgical monitoring and antibiotics. The alternate level of care would have also allowed for overnight monitoring (if needed).

The records reference MCG in the health plan denial letter. These criteria indicate that in the absence of hemodynamic instability, sepsis or toxicity, significant electrolyte imbalance, bleeding, gastrointestinal (GI) obstruction or surgical complications the procedure may be performed without an inpatient admission. In this case the patient tolerated oral hydration, a diet and medication and his pain was well controlled. An alternate level of care would have appropriately provided for a presurgical assessment, the laparoscopic appendectomy, and post-surgical monitoring, the provision of antibiotics and pain medications. An inpatient level of care was not required or medically necessary in this case according to the referenced MCG or generally accepted medical standards.