Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain 
Treatment: Inpatient admission 
The insurer denied coverage for inpatient admission. 
The denial is upheld. 

According to the documentation submitted, this is an adult male who presented to the emergency department (ED) with the complaint of right lower quadrant (RLQ) abdominal pain starting early in the morning. According to the triage note the patient was afebrile with stable vital signs. As per the provider note the patient presented with abdominal pain. Past medical history was negative.  Examination revealed Right Lower Quadrant tenderness. The principal diagnosis was acute appendicitis. The patient was admitted. White blood cell (WBC) count was 16.08. Zosyn was ordered for antibiotic. 

The patient underwent an uneventful laparoscopic appendectomy. The post operative note indicated the patient was recovering appropriately and being monitored for sleep apnea. He was seen in recovery. The pain was controlled. The patient was doing well and tolerating diet and was cleared for discharge to home. 

Based upon the records, the patient did not require acute inpatient admission. He did not require an acute inpatient admission but rather observation status as he did not have any complications from the surgery that warranted inpatient care. The laparoscopic appendectomy was uneventful, and this was a non-perforated appendicitis. There was no evidence of a complicated post operative course requiring hospitalization. Thus, the patient should have had the appendectomy performed under an observation status without acute inpatient admission. According to Milliman Care Guidelines (MCG) Health Inpatient and Surgical Care 27th 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 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 should have been discharged following observation within a 23-hour observation period following surgery. In addition the operative status criteria is ambulatory. 

In addition, Milliman Care Guidelines also notes that: "A study of 376 adult patients (mean age 35 years) who underwent laparoscopic appendectomy for uncomplicated appendicitis found that 80% were managed on an outpatient basis. Analysis of 563 adult patients (mean age 36 years) who underwent laparoscopic appendectomy for uncomplicated appendicitis found that 86% were treated on an outpatient basis. A cohort of 871 adults (mean age 35 years) with uncomplicated appendicitis who underwent laparoscopic appendectomy had a mean length of stay of 17.5 hours. Analysis of procedure data for a large commercially insured adult population shows 88% of laparoscopic appendectomies performed on patients with appendicitis without peritonitis or abscess being performed on an outpatient basis." Thus observation/ ambulatory status is justified in this case. 

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 the inpatient admission is not substantiated.