Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Right lower quadrant pain.
Treatment:  Inpatient admission.

The insurer denied coverage for inpatient admission.  The denial is upheld.

According to the history and physical, the patient has a past medical history of hypertension (HTN), diabetes mellitus (DM), orthotopic liver transplant (OLT) over 20 years ago. The patient was sent for direct admission from the Liver Clinic because of fever and right lower quadrant (RLQ) pain. The patient had a fever of 101 degrees Fahrenheit the prior day with 3 episodes of emesis (vomiting). On exam the patient's abdomen was soft and tender to palpation in the right lower quadrant (RLQ).  White blood cell (WBC) count was 13.8 and creatinine was 1.6. The plan was to obtain a computed tomography (CT) of the abdomen and hold Cellcept for given infection. The patient was admitted to liver medicine.

The progress note indicated the computed tomography (CT) scan results showed acute appendicitis and surgery was consulted for an appendectomy. Zosyn was started.

Surgery saw the patient and noted the history of right lower quadrant (RLQ) pain. The patient was tolerating oral intake. The white blood cell (WBC) count was down to 8.8. computed tomography (CT) results were noted showing a fluid filled appendix with fat stranding in the RLQ. The plan was laparoscopic appendectomy the following day.  The patient underwent a laparoscopic appendectomy and repair of an umbilical hernia. The surgery was uneventful. 

The laparoscopic appendectomy was uneventful and there was no perforation. There was no evidence of a complicated post operative course requiring hospitalization. The patient was referred for direct admission and was not taken to surgery until two days later and was then discharged the following day. The patient could have been seen the same day of admission for surgery and could have been discharged to home later that day without being a being acute admission but rather observation. 

According to Milliman Care Guidelines (MCG) Health Inpatient and Surgical Care 27th Edition Appendectomy, without Abscess or Peritonitis, by laparoscopy ORG: S-175 (ISC) optimal recovery course includes floor to discharge with 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. 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. In addition, the operative status criteria is ambulatory.   

Milliman Care Guidelines (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 criteria that were not met. 

Based upon these guidelines, this patient did not have any indication as noted above for inpatient stay or prolonged stay. The patient had a non-perforated appendicitis and underwent an uneventful lap appendectomy.  

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 hospital admission is not substantiated.