Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis. 
Treatment: Inpatient admission. 

The insurer denied coverage for an inpatient admission. 

The denial is upheld. 

This is an adult patient with no past medical history who presented to the Emergency Department (ED). The patient presented with right sided lower abdominal pain that started on the day of presentation and without vomiting. The patient was afebrile with stable vital signs. The History and Physical indicated the patient presented with less than 24 hours of Right Lower Quadrant (RLQ) pain not associated with nausea, vomiting, fever, or chills. The exam revealed the abdomen to be soft, non-tender to palpation without rebound, tenderness or guarding. White Blood Cell (WBC) was 13.14. A Computed Tomography (CT) of the abdomen revealed acute appendicitis with likely contained perforation with a 1.1-centimeter (cm) fluid collection along the distal wall. Multiple distal appendiceal diverticuli were noted as well. The patient was admitted to surgery for laparoscopic (lap) appendectomy. 

According to MCG (Milliman Care Guidelines) Health Inpatient and Surgical Care 26th 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; 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. Furthermore, according to MCG, the operative status criteria is ambulatory. Based upon the records provided, the patient reached these milestones, and could have been discharged following observation within a 24-hour observation period following surgery. Furthermore, according to MCG, the operative status criteria is ambulatory. The patient did not have any comorbidities that required treatment at the time that would have extended the stay. The patient did not require any significant preoperative optimization prior to going to surgery. The patient did not have a perforated appendix or abscess. Thus, in this case the patient should have had the procedure done under ambulatory status and not an acute admission as the patient did not require an acute inpatient setting and there was no indication for an extended stay with inpatient status. 

To summarize, the reviewer feels that the inpatient admission was not medically necessary at the acute inpatient level and denial for hospital admission should be upheld. The patient was admitted and underwent an uneventful lap appendectomy - all of which could have been done in an observation status. Finally, the reviewer is knowledgeable in this condition and the recommended health care services provided for this condition and therefore feel that the medical necessity of the inpatient admission was not justified, as observation status was sufficient. The reviewer does believe that based upon these findings the health care plan did act reasonably and with sound medical judgment. 

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 inpatient admission is not substantiated.