Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis

Treatment: inpatient hospital admission

The insurer denied coverage for the inpatient hospital admission

The denial is upheld

According to the documentation, this is a male patient with no past medical history. As per the Emergency Department (ED) note the patient was hospitalized at another facility with an appendicitis 10 days earlier. No surgery was performed. He was discharged on antibiotics.  He came to the ED and felt abdominal discomfort has not improved in the past week. Exam revealed the abdomen to be soft, mild tenderness on deep palpation in the right lower quadrant (RLQ). The assessment was appendicitis. White blood cell (WBC) count was 7.5. The plan was to admit to surgery and the patient preferred to defer surgery pending attending evaluation. The patient was afebrile and remained afebrile throughout the hospital course. An abdominal ultrasound did not reveal the appendix. Computed tomography (CT) of the abdomen showed an appendix up to 11 millimeters (mm) in size with mild surrounding fat stranding suggestive of acute appendicitis.

Progress notes the following day indicated the patient's only complaint was discomfort and fatigue when he walked several blocks. He had no fever and stable vital signs. WBC was normal. They discussed finishing his course of antibiotic and considered an interval appendectomy in a few weeks if he was concerned about future recurrence. He preferred operation now but understood that there may be related complications. General surgery notes indicated the patient had no acute events overnight and had some improvement in pain and denied nausea or vomiting. Intravenous (IV) antibiotics continued. His abdomen was soft, non distended and tender to palpation. The plan was for patient to be tentatively on the add-on surgery schedule.

Progress notes indicated the patient was ambivalent about having the operation. The patient was seen by gastroenterology (GI) and primary medical doctor (PMD) prior to admission and neither of whom felt his exam warranted hospital admission or operation. Rather they both suggested outpatient CT but patient came to the hospital to facilitate this. His abdomen was benign, and he was afebrile with normal WBC. The hospital provider noted that he can be observed today, continue antibiotics and if better tomorrow can be discharged to home with follow up in the office and consider interval appendectomy in 6-8 weeks.

Progress notes on 2 days later indicated the patient was feeling better and denied pain or vomiting. WBC was 6.2. The patient was discharged to home. 

According to MCG (Milliman Care Guidelines) Health Inpatient and Surgical Care 25th Edition Appendectomy, without Abscess or Peritonitis, by laparoscopy ORG: S-175 (ISC), the operative status criteria is ambulatory. Thus, even if an appendectomy was to be performed, it would have been in an ambulatory/observation status.

The progress note noted that the patient can be observed and that clinically if stable can be discharged with outpatient follow up and interval appendectomy. Furthermore, the progress note indicated that the patient was told by his GI provider and PMD that he did not need to be admitted. He did not have an elevated WBC, did not have a fever, and only had mild symptoms and needed to complete the antibiotics. He did not need inpatient admission for this as the surgeon also recommended an interval appendectomy 6-8 weeks later. Thus, no surgery was planned. The patient did not require acute inpatient admission as the patient could have been cared for based upon an observation admission.

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

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