Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute suppurative appendicitis
Treatment: Full hospital admission
The insurer denied coverage for a full hospital admission.
The denial is upheld.

This is an adult with past medical history of endometriosis who presented with abdominal pain, nausea, and vomiting. The pain started in the evening and was diffuse. On exam, she was in no acute distress and not ill appearing. The abdomen was soft with tenderness to palpation in the lower abdomen R>L (right more than left). There was no guarding or rebound. The history noted that the patient was a transfer from an area hospital for rule/out appendicitis. She was afebrile with stable vital signs. There was no abdominal tenderness. Computed tomography (CT) showed appendix partially filled with enteric contrast with an un-opacified segment up to 14 mm in diameter with no peri-appendiceal fat stranding. White blood cells (WBC) were 11.2.

Surgery noted that the patient was transferred with abdominal pain associated with nausea and vomiting. The patient was hemodynamically stable, non-toxic appearing with a non-distended abdomen and mild tenderness in the LLQ (left lower quadrant) and RLQ (right lower quadrant). The plan was intravenous (IV) antibiotics and consent for lap (laparoscopic) appendectomy.

The patient was taken to the operating room and underwent an uneventful laparoscopic appendectomy. The findings were acute appendicitis with perforated appendiceal tip. No drains were placed. Pathology revealed acute suppurative appendicitis. 

According to Milliman Care Guidelines (MCG) Health Inpatient and Surgical Care 26th Edition Appendectomy, without Abscess or Peritonitis, by laparoscopy, optimal recovery course includes floor to discharge with the following milestones completed: hemodynamic stability; procedure completed; no evidence of post op (operative) 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, the patient reached these milestones, and could have been discharged following observation within a 23-hour observation period following surgery. According to MCG, the operative status criteria is ambulatory. MCG also notes extended stay may be indicated and defined as Minimal (a few hours to 1 day), Brief (1 to 3 days), Moderate (4 to 7 days), and Prolonged (more than 7 days). Inpatient stay may be needed for: Failure to achieve discharge status criteria; Complicated appendicitis with discovery or development of peritonitis, intra-abdominal abscess, or prolonged fever may require conversion to an open procedure or longer observation on parenteral antibiotics and one can expect brief stay extension; Clinically active comorbidities (require more prolonged postoperative care) and anticipate treatment directed at particular comorbidity (e.g., [congestive heart failure] CHF, acute kidney injury (Stage 2), Acute renal failure (Stage 3 acute kidney injury), chronic obstructive pulmonary disease (COPD), cirrhosis)s, or Surgery may be delayed pending medical optimization of comorbid conditions and one can expect brief stay extension; Complications such as wound infection, wound dehiscence, or enterocutaneous fistula and require continued observation, percutaneous drainage, or reoperation and one can expect brief stay extension; Continued ileus with inability to tolerate oral intake may require continued stay and one can expect brief stay extension; Postoperative bleeding which may require reoperation and one can expect brief stay extension. 

The patient did not have any comorbidities that required treatment at the time that would have extended her stay. She did not have peritonitis. She did not require any significant preop optimization prior to going to surgery. Based upon the records provided, the patient did not require an acute inpatient admission but rather observation status. She did not have any complications from the surgery that warranted inpatient care. There was no evidence of a complicated post operative course requiring hospitalization. 

The medical necessity of the acute admission was not justified, as observation status was sufficient. 

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

The medical necessity for inpatient admission services is not substantiated