Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld

This patient is an adult male who presented to the emergency department with the complaint of abdominal pain, nausea and vomiting of three to four days duration. The patient's examination revealed abdominal tenderness in the right lower quadrant. Vital signs identified a normal temperature at the time of presentation. The heart rate was 90 beats per minute. The white blood cell (WBC) count was normal at 10 thousand (K). Abdominal computed tomography (CT) scan was completed showing findings consistent with acute appendicitis. Surgical consultation was obtained, and the patient was admitted to the hospital and started on intravenous (IV) antibiotics. On day #1 the patient underwent laparoscopic appendectomy. Operative findings included a contained perforation of the base of the appendix. A surgical drain was placed. The operation was completed without complication. The patient was monitored following surgery and 
remained stable. The day #2 progress note indicates that the patient was without new complaint. He had normal vital signs on day #2 and day #3. The patient was started on a diet on day #2 and continued with intravenous antibiotics. He was discharged from the hospital on day #3 following the initial surgical recovery with instructions for surgical follow up.
The health plan rationale for denial is that there is no documentation of need for an inpatient level of care and the care rendered could have been provided without full admission to the hospital. The care provided could have been rendered with an observation status. This letter references Milliman Care Guidelines (MCG) criteria.

The inpatient care was not medically necessary for this patient.

The health plan rationale for denial is that there is no documentation of need for an inpatient level of care and the care rendered could have been provided without full admission to the hospital. The submitted medical records do not indicate that there were hemodynamic, pulmonary, neurological, or metabolic reasons for an acute inpatient level of care. Vital signs were normal at the time of emergency department presentation. There 
was no complication of surgery and this operation is typically performed without need for full inpatient admission. Inpatient care for this patient was not medically necessary based on 
the standard of care. The care provided during this time could have reasonably and appropriately been provided with a lower level of care. A lower level of care would have provided for emergency department assessment, provision of intravenous fluid and antibiotics, surgical consultation, surgery to remove the appendix and overnight monitoring. This patient was clinically stable at the time of presentation to the emergency department, he remained stable throughout the perioperative period and was able to be discharged from the hospital following an uncomplicated initial recovery on the second post-surgical day.
Generally accepted medical standards indicate that in the absence of hemodynamic instability, sepsis or toxicity, significant electrolyte imbalance, bleeding, gastrointestinal (GI) obstruction or surgical complications, treatment as provided in this case could be provided without an inpatient level of care. In this case the patient tolerated oral hydration by post op day #1. A lower level of care would have appropriately provided for treatment and monitoring. Inpatient care was not required or medically necessary in this case per generally accepted medical standards.