Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis. 
Treatment: Continued inpatient admission.

The insurer denied the inpatient admission. The denial was upheld.  

This is a male patient with history of hypertension who presented to the Emergency Department (ED) with complaints of intermittent abdominal pain, fever and chills for several days. The patient was seen at the urgent care facility and had a computed tomography (CT) scan that was concerning for acute appendicitis. The patient's exam revealed soft abdomen with right-sided tenderness to palpation with no guarding. The patient was started on intravenous (IV) antibiotics including ceftriaxone, Flagyl, and IV fluids. The patient's white blood cell (WBC) count was 12.6. The patient was admitted to the hospital and underwent an uneventful laparoscopic appendectomy. The pathology report revealed acute appendicitis. After a period of medically stability the patient was discharged. 

Based on the review of the medical record and literature, inpatient admission was not medically necessary for this patient. The patient presented to the hospital and was admitted and was taken to the operating room on and was discharged later that day after an uneventful lap appendectomy. The patient did well post-operatively and had stable vital signs. The patient was sent home on the same day after a brief period of observation. The patient did not require an acute inpatient admission but rather observation status as he did not have any complications from the surgery that warranted inpatient level of care. The patient's lap appendectomy was uneventful and there was no perforation noted. There was no evidence of a complicated post-operative course requiring hospitalization. Thus, the patient's care could have been safely provided at the observational level of care after the appendectomy procedure. 

Based upon the MCG Health Inpatient and Surgical Care 24th Edition Appendectomy, without Abscess or Peritonitis, by Laparoscopy ORG: S-175 (ISC) optimal recovery course includes floor to discharge with the following milestones completed: hemodynamic stability; successfully uncomplicated lap appendectomy; 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. In this case, the patient reached these milestones, and could have been discharged following observation.  Furthermore, according to MCG, the goal length of stay is ambulatory. The patient did not have any co-morbidities that warranted inpatient admission. 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). The patient should have had the procedure done under ambulatory/observation status as he did not require an acute inpatient setting as he was sent home after the lap appendectomy on the same day of surgery. Thus, inpatient admission was not medically necessary for this patient. 

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

The carrier's denial of coverage for the continued inpatient level of care should be upheld. The medical necessity is not substantiated.