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.

This is an adult who presented to the emergency department (ED) with a complaint of 2-day history of abdominal pain associated with nausea and vomiting. The patient was afebrile with stable vital signs. On exam, the patient had a soft nontender, non-distended abdomen. White blood cell (WBC) count was 14.2. Computed tomography (CT) of the abdomen revealed a 2.4 centimeters (cm) diameter appendix with surrounding inflammation and appendicolith concerning for acute appendicitis.

The patient underwent an open appendectomy. The patient was given Zosyn which was to be discontinued in 24 hours as per the pharmacist. Surgery was uneventful. Pathology revealed necrotizing acute appendicitis with micro abscess and acute serositis. Postoperative progress note indicated the patient was doing well with pain controlled. The patient was hemodynamically stable, tolerating a clear liquid diet. Progress notes indicated the patient had no active complaints and the pain was improved. The patient was tolerating a regular diet and was discharged home.

The test results showed infection at the tip of the appendix. This surgery is usually done as a short stay (ambulatory surgery). There are no notes that the patient was unstable and needed treatment for longer than observation level of care. There are no notes that the patient was not able to eat or drink after treatment or that the patient needed monitoring after the surgery for longer than observation level of care. There is no documentation indicating that the patient had problems during or after the surgery that did not improve, and the patient had no uncontrolled bleeding during or after the surgery.

The open appendectomy was uneventful, and this was a non-perforated appendicitis. There was no evidence of a complicated postoperative course requiring hospitalization.

According to Milliman Care Guidelines (MCG) Health Inpatient and Surgical Care 27th Edition Appendectomy, without Abscess or Peritonitis, by laparoscopy ORG: S-170 (ISC) optimal recovery course includes floor to discharge with the following milestones completed: hemodynamic stability, procedure completed, no evidence of postoperative 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.

Furthermore, MCG Health noted in General recovery care 27th Edition General admission criteria GRG: CG-GAC (ISC GRG) that admission is indicated for 1 or more of the following: hemodynamic instability, acute cardiac or peripheral ischemia, cardiac arrhythmias of immediate concern, severe respiratory findings, severe airflow or ventilation abnormalities, Anasarca, neurologic abnormalities, altered mental status that is severe or persistent, physiologic disorder (such as acute acidosis, thyroid storm, adrenal crisis) that is severe or persists despite observation care, rectal temperature less than 95 degrees Fahrenheit, severe electrolyte abnormalities requiring inpatient care, severe anemia, adverse drug or systemic toxin reaction that is severe or persists despite observation, severe pain requiring acute inpatient management, treatment requiring inpatient care, emergency procedures needed. Based upon these guidelines this patient should have been observed rather than placed in an acute admission as the patient did not have any indication as noted above for an inpatient stay or prolonged stay.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably, with sound medical judgment, and in the best interest of the patient.

The medical necessity for the inpatient hospital admission is substantiated.