Appeal type: Medical necessity
Decision: Upheld

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

This is a case of a female child who presented to the emergency department (ED) with pain of 9/10. The patient was afebrile with stable vital signs. On exam, her abdomen was soft, non-distended with tenderness to palpation in the left lower quadrant (LLQ) and right lower quadrant (RLQ). Computerized tomography (CT) showed the appendix not to be clearly delineated. Pediatric surgery saw the patient, noted the history of abdominal pain and that the pain has improved since being at the hospital. She denied nausea or vomiting and did have a regular bowel movement. White blood cells (WBC) were 11.8. 

The patient was nothing by mouth (NPO) and started on Zosyn. The patient was taken to the operating room and the path revealed appendix was histologically unremarkable. Surgery was uneventful and there was no evidence of peritonitis. The operative note indicated the patient could be discharged in the morning. Progress note indicated pain was being managed and diet was advanced. The patient did well and was discharged.

There was no sign that the patient had a health issue needing the patient to stay. The patient had a procedure without problems during or after that required inpatient admission. The services performed after the surgery could have been done while in observation. This is based on Milliman Care Guidelines (MCG) criteria appendectomy, without abscess or peritonitis, by laparoscopy, pediatric, 25th edition. 

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- Health Inpatient and Surgical Care 26th Edition Appendectomy, uncomplicated, open or laparoscopic the Operative Status Criteria is ambulatory with the goal length of stay is ambulatory. Extended Stay as defined by Minimal (a few hours to 1 day), Brief (1 to 3 days), Moderate (4 to 7 days), and Prolonged (more than 7 days) may be needed for: failure to achieve discharge status; prolonged fever and prolonged fever may require longer observation in hospital on parenteral antibiotics and one can expect brief stay extension; complicated appendicitis with discovery or development of generalized peritonitis or intra-abdominal abscess may require conversion to an open procedure or longer observation on parenteral antibiotics; complications such as wound infection, intra-abdominal abscess, fecal fistula, pylephlebitis, and intestinal obstruction may occur and require continued observation, percutaneous drainage or reoperation and one can expect brief to moderate stay extension; prolonged ileus with prolonged ileus may delay initiation of feeding and one can expect brief stay extension; or postoperative bleeding may require reoperation and one can expect brief stay extension.  

None of these situations were seen in this case as the patient had an uncomplicated non-perforated appendicitis and did not have any complication post-surgery. This patient did not have any factors that required hospitalization, or any other factors present that would have required prolonged hospitalization (e.g., ileus, postop bleeding, and signs of peritonitis, wound infection, or complication), or any co morbidities that required treatment at the time that would have extended his stay. 

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

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