Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis
Treatment: Inpatient Hospital Stay
The health plan denied the requested inpatient hospital stay as not medically necessary.
The health plan's determination is upheld.

The patient is a man who presented to the hospital emergency department (ED) as a transfer patient from an urgent care facility with a history of progressively worsening abdominal pain of two-days duration. Comorbid health conditions included benign prostatic hypertrophy. Evaluation included a physical exam, labs, and a computed tomography (CT) scan of the abdomen. He was without fever at the time of presentation. The heart rate was 85/beats per minute in the ED. Lab data identified a normal white blood cell count (WBC) count. The CT scan yielded the diagnosis of uncomplicated acute appendicitis. Treatment was initiated with intravenous (IV) fluid and antibiotics.

The patient underwent a laparoscopic appendectomy. The clinical notes and the anesthetic record indicate an uncomplicated appendectomy procedure. The appendix was inflamed, consistent with acute appendicitis. He was provided IV fluid and perioperative antibiotics. Vital signs remained normal throughout the hospitalization without fever. Diet was advanced and pain management was converted to oral medications. He was discharged home.
The material sent for review includes the hospital appeal letter that references Milliman Care Guidelines (MCG) 25th edition-General Admission Criteria.

At issue is the medical necessity for the inpatient stay. The health plan's determination of medical necessity is upheld, in whole. Acute inpatient admission was not medically necessary for this patient.

This patient presented to the ED with abdominal pain. The evaluation with examination, lab data, and a CT scan established the presumptive diagnosis of appendicitis. The initial treatment appropriately included nothing by mouth (NPO) status, IV fluid, and an appendectomy performed. The early post-surgical course was uncomplicated, and the patient was clinically stable for discharge from the hospital following surgery.
The submitted clinical documentation does not support the need for inpatient admission for this patient. The patient presented with abdominal pain and underwent an uncomplicated appendectomy. There were no perioperative complications that mandated an inpatient designation. An alternate level of care would have satisfactorily provided for the care provided and would have been consistent with the accepted standard of medical care.

The care provided could have been rendered with an alternate level of care status. The records reference MCG Inpatient and Surgical Care, 25th Edition. These criteria state that the goal length of stay is ambulatory or 2 days postoperative. 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 with an ambulatory level of care. In this case, the patient tolerated oral hydration, diet and medication and pain was well controlled. An alternate level of care could have been appropriately provided for presurgical assessment, appendectomy as performed, and post-surgical monitoring. Inpatient care was not required or medically necessary in this case, per the submitted MCG or generally accepted medical standards.