Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis 
Treatment: Inpatient hospital stay.
The insurer has denied coverage for inpatient hospital stay.
The denial is upheld.

This is a female patient with history of asthma, migraines, and immunodeficiency disease. The patient presented to the emergency department with worsening right upper quadrant (RUQ) abdominal pain for several days. The patient's initial ED vital signs were: blood pressure (BP) 121/81, heart rate (HR) 88, respiratory rate (RR) 18, Temperature 98.4 and blood oxygen level 100%. An examination was performed that revealed tenderness in the right upper quadrant and right lower quadrant without rebound or guarding. An ultrasound of the abdomen was performed that revealed a probable acute appendicitis and was negative for acute cholecystitis. The patient was placed nothing by mouth (NPO) for operating room (OR). The patient underwent laparoscopic appendectomy under general anesthesia. The patient experiences no post-operative complications and was able to tolerate a diet. The patient was discharged. 

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. Based upon the records provided, the patient reached these milestones, and could have been discharged following observation. Furthermore, according to the MCG, the goal length of stay is ambulatory. In this case, the patient did not have any comorbidities that warranted inpatient admission. Extended stay may be indicated and defined as Minimal (a few
hours to 1 day), Brief (1 to 3 days), Moderate (4 to 7 days), and Prolonged (more than 7 days).  Extended stay beyond goal length of stay may be needed for: 1) inpatient stay may be needed for failure to achieve discharge status criteria; 2) Complicated appendicitis-discovery or development of peritonitis, intra-abdominal abscess, or prolonged fever may require longer observation on parenteral antibiotics and one can expect brief extension. 3) Clinically active comorbidities and anticipate treatment directed at particular comorbidity and one can expect brief stay extension; 4) Complication- such as wound infection, wound dehiscence, or enterocutaneous fistula and require continued observation, percutaneous drainage, or  reoperation and one can expect brief extension. 5) Continued ileus with inability to tolerate oral intake may require continued stay and one can expect brief stay extension. 6) Postoperative bleeding may require reoperation and one can expect brief extension. 

The patient presented to the hospital and was admitted and had the diagnosis made that this was appendicitis and not cholecystitis by approximately 12 noon. The patient did not require an acute inpatient admission but rather observation status as she did not have any complications from the surgery that warranted inpatient level of care. The lap appendectomy was uneventful and there was no perforation as noted. There was no evidence of a complicated post op course requiring hospitalization. Thus, the patient could have had the appendectomy performed under an observation status without an inpatient admission.

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 inpatient hospital stay should be upheld. The medical necessity is not substantiated.