Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Inpatient Hospital. 
Insurer denied inpatient stay. 
The denial is overturned.

The patient is a male who presented to the emergency department (ED) with a history of progressively worsening abdominal pain and nausea. He was previously admitted to the hospital for the condition of appendicitis and was treated non-operatively. Comorbid health conditions included morbid obesity, gastroesophageal reflux disease (GERD), hyperlipidemia. His evaluation included physical exam, labs, and computed tomography (CT) scan. He was without fever at the time of presentation. The heart rate was 76/minute. Lab data identified a white blood cell (WBC) count of 12.2 thousand (K). Computed tomography (CT) scan yielded the diagnosis of acute appendicitis. Treatment was initiated with intravenous (IV) fluid and antibiotics. Surgical consultation was obtained.

The patient underwent laparoscopic appendectomy. The clinical notes and the anesthetic record indicate an uncomplicated appendectomy. The operative note describes an acute perforated appendicitis with purulent fluid throughout the abdomen. He was provided IV fluid and perioperative antibiotics. The vital signs remained normal following surgery. The patient reported abdominal bloating but had normal vital signs. The WBC count was 10.7 K. The patient was receiving anti-emetic medication for nausea and had not yet had flatus or a bowel movement. The patient was having bowel movements. He was ambulating and pain was controlled. He was maintained nothing by mouth (NPO). He was evaluated with an abdominal CT scan that showed a fluid collection in the right lower abdomen suspicious for abscess. The small bowel was dilated to 5.1-centimeters (cm) consistent with ileus or possible bowel obstruction. Consideration was given for drainage of the fluid collection by interventional radiology, but this was deemed not feasible.  The patient tolerated a diet and had a normal WBC count (7.7 K). He was discharged from the hospital.

The health plan's determination is overturned.

In this case of a perforated appendicitis complicated by post-operative ileus and abdominal fluid collection, the inpatient stay was medically necessary and was consistent with medical standards. Based on this patient's presenting condition, diagnostic test results, and clinical status, an inpatient level of care during this time was medically necessary and appropriate.
Acute inpatient admission was medically necessary for this patient because the patient had perforated appendicitis that was appropriately treated with surgery and continued provision of parenteral antibiotics in the post-surgical period. The operative note describes purulent fluid throughout the abdomen. He required provision of intravenous fluid during his initial recovery while he was kept NPO during a period of post-surgical ileus. He also required follow up imaging with CT scan as performed that identified a surgical site fluid collection consistent with abscess. The records support that this patient was treated with timely surgical treatment and parenteral antibiotic therapy was continued in the post-surgical period. This patient's post-surgical ileus mandated continued inpatient care and clinical follow up with monitoring and lab assessment. Once the patient demonstrated normal vital signs and tolerance of oral intake he was appropriately discharged from the hospital.