Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis

Treatment: Inpatient admission

The insurer denied the inpatient admission.

The denial was upheld.  

This is a male patient with a history of several episodes of appendicitis that was managed medically. He presented to the Emergency Department (ED) with complaints of abdominal pain and vomiting. The patient's initial exam showed abdominal pain on the right upper quadrant (RUQ) and right lower quadrant (RLQ), voluntary guarding on the RLQ, positive McBurney's sign, and abdominal rebound. The patient was given morphine for his severe pain. Intravenous (IV) fluids were started and the patient's abdominal sonogram was unable to visualize the appendix. The patient's white blood cell (WBC) count was 13.7. Surgery was consulted. The patient was started on IV antibiotics; Ciprofloxacin and Flagyl. The patient developed a fever to 103. A computed tomography (CT) of the abdomen was performed that revealed thickened retrocecal appendix with peri-appendiceal fat stranding and fluid, which was suspicious for perforated acute appendicitis.
The patient was admitted to the hospital for further work up. The patient underwent laparoscopic appendectomy without complications. After a period of medical stability the patient was discharged home.

As per the MCG- Health Inpatient and Surgical Care 24th Edition Appendectomy, uncomplicated, open or laparoscopic ORG: P-20 (ISC) the Operative Status Criteria is ambulatory with the goal length of stay is ambulatory. Extended Stay is defined by Minimal (a few hours to 1 day), Brief (1 to 3 days), Moderate (4 to 7 days), and Prolonged (more than 7 days), and it may be needed for: failure to achieve discharge status; prolonged fever and prolonged fever may require longer observation in hospital on parenteral antibiotics and one can expect brief stay extension; complicated appendicitis with discovery or development of generalized peritonitis or intra-abdominal abscess may require longer observation on parenteral antibiotics; complications such as wound infection, intra-abdominal abscess, fecal fistula, pylephlebitis, and intestinal obstruction may occur and require continued observation or reoperation and one can expect brief to moderate stay extension; prolonged ileus with prolonged ileus may delay initiation of feeding and one can expect brief stay extension; or postoperative bleeding may require reoperation and one can expect brief stay extension. However, in this case, this patient's clinical condition did not require extended hospital stay. 

Based on the review of the medical record and literature, inpatient admission was not medically necessary for this patient. The patient was admitted on 10/9/19 and was taken to the operating room for lap appendectomy. The patient underwent an uneventful lap appendectomy which was non-perforated.  The patient did not need further acute level of care following the appendectomy. The patient did not have any sign of an abscess or perforation at the time of surgery. The patient could have been cared for based upon a 23-hour observation admission.

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

Based on the above, the medical necessity for the inpatient admission stay is not substantiated.  The insurer's denial should be upheld.