Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain; Shortness of breath
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male. His medical history included hypertension; diabetes mellitus, type 2; dyslipidemia; hypothyroidism; and obesity. His surgical history included cardiac catheterization and umbilical hernia repair. The patient presented to an emergency department with a three-day history of shortness of breath, cough, nausea, vomiting, lower abdominal pain, bloating, decreased flatus, and dysuria.

The patient's vital signs were as follows: temperature 99.1, pulse 62, blood pressure 154/74, respirations 18, oxygenation 98%. Physical examination demonstrated abdominal tenderness and distention. Serum laboratories demonstrated leukocytosis to 21.45 and elevated creatinine to 1.54. Computed tomography demonstrated bilateral hydro-nephrosis, hydro-ureter, and urinary-bladder distention "compatible with bladder outlet obstruction or neurogenic bladder"; and distal appendiceal mucocele.

The patient was admitted at an acute inpatient level of care for urinary retention and appendiceal mucocele. The patient was made nil per os [NPO]; and provided with intravenous fluids, antibiotics, analgesics, and antiemetics. For urinary retention, urology consultation recommended Foley catheter placement and outpatient follow-up. For appendiceal mucocele, general surgery consultation recommended laparoscopic appendectomy, but the patient declined.

The patient returned to his baseline health and function, and was discharged home in good and stable condition with a Foley catheter, oral antibiotics, and outpatient urologic and surgical follow-up.

No, the Inpatient admission was not medically necessary.

The patient was admitted with two diagnoses: urinary retention and appendiceal mucocele.

1) Urinary retention. The patient did not require admission for urinary retention. Indeed, urologic consultation recommended Foley catheter placement and outpatient follow-up.

2) Appendiceal mucocele. The patient was admitted at an acute inpatient level of care for treatment of his appendiceal mucocele -- the General Surgery Service offered laparoscopic appendectomy.

If the patient had proceeded with surgery, in the absence of significant co-morbidities, physiologic derangements, or complications, laparoscopic appendectomy could have been performed effectively and safely on outpatient or observational status [Gilliam et al; Cross et al; Cosse et al]. In fact, most patients could be discharged from the post-anesthesia care unit -- the recovery room --, precluding the need for inpatient admission [Mitchell et al; Dubois et al; Cash et al].

Even if the patient did not proceed with surgery -- instead, preferring medical management -- he could have been treated on an outpatient bases with antibiotics.

Therefore, for this patient, there was no need for admission at an acute inpatient level of care whether he chose operative or non-operative management for his mucocele.

Patients who undergo laparoscopic appendectomy can be treated effectively and safely on outpatient or observational status; most patients can be discharged from the recovery room. Patients who undergo medical management can be treated effectively and safety on outpatient status.