Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute appendicitis.
Treatment: Inpatient hospital admission.
The insurer denied coverage for the inpatient hospital admission.
The denial is upheld. 

This is a female patient with a history of ovarian cysts, gastroesophageal reflux disease (GERD), hyperlipidemia and hypertension (HTN) who  presented to the hospital for complaints of a one day history of periumbilical abdominal pain that moved down to the right lower quadrant (RLQ). The patient also complained of nausea. The patient's abdomen was soft, non-distended with pain over the McBurney's point. The patient was afebrile. Her white blood cell (WBC) count was 9.7. Her computed tomography (CT) scan of the abdomen revealed thickened appendix with mild peri-appendiceal inflammation and findings that may represent acute appendicitis. The patient also had cysts of the right ovary which may be hemorrhagic. The diagnosis was acute appendicitis. General surgery admitted the patient with the plan of intravenous (IV) antibiotics and consent for the operating room. The patient was taken to the operating room on day 2 of admission and underwent an uneventful laparoscopic (lap) appendectomy. The operative note indicated there was no perforation on gross examination and no abscess was noted. Pathology revealed an appendix with mural chronic inflammation and peri-appendiceal acute inflammation and serositis. Postoperative check revealed the patient denied nausea or vomiting. Her vital signs were stable. The plan was antibiotics, regular diet and pain control. Postoperatively, the patient did well and was discharged on day 3 of admission. 

Based upon the Milliman Care Guidelines (MCG) Health Inpatient and Surgical Care 24th 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; successfully uncomplicated lap appendectomy; 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 could have been discharged following observation within a 23-hour observation period. Furthermore, according to MCG, the goal length of stay is ambulatory. The patient did not have any comorbidity that warranted an inpatient admission. The patient's ovarian cyst was not a reason for prolonged hospitalization. As per MCG guidelines, extended stay may be indicated and defined as Minimal (a few hours to 1 day), Brief (1 to 3 days), Moderate (4 to 7 days), and Prolonged (more than 7 days). The patient could have had the procedure done under ambulatory/observation status as she did not require an acute inpatient setting.

The patient's care could have been safely provided at a lower level of care. The patient presented to the hospital and underwent an uneventful lap appendectomy. She did well postoperatively and had stable vital signs and was tolerating diet. She did not require an acute inpatient admission but rather an observation status as she did not have any complications from the surgery that warranted inpatient level of care. The lap appendectomy was uneventful and there was no perforation as noted in the operative note. There was no evidence of a complicated postoperative course requiring hospitalization. The patient could have had the appendectomy performed under an observation status without an inpatient admission. 

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

The medical necessity for the inpatient hospital admission is not substantiated. The insurer's denial should be upheld.