Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis

Treatment: Inpatient hospital

The insurer denied coverage for inpatient hospital.

The denial is upheld.
 

According to the triage note, the patient complained of right lower quadrant (RLQ) pain and flank pain, and nausea since the night before. Past medical history was negative. The patient was afebrile with stable vital signs. As per the Emergency Department (ED) provider note, the patient is an adult female with abdominal pain that began the night before; started in middle of abdomen and radiated to the back and right lower abdomen. She denied vomiting, fevers, chills. On exam the abdomen was soft, no rebound or guarding. The White blood cells (WBC) were 15.24. Computed tomography (CT) of the abdomen showed prominent appendix containing proximal appendicolith; correlate clinically for possible early developing appendicitis. The patient was admitted for the principal diagnosis of acute appendicitis. The patient was admitted and taken to the operating room and underwent an uncomplicated laparoscopic appendectomy. The patient did well and was discharged the same day. 

Based upon the records, the patient did not require acute inpatient admission since she should have been managed in an observation status. She did not require an acute inpatient admission but rather observation status as she did not have any complications from the surgery that warranted inpatient care. The laparoscopic appendectomy was uneventful and there was no perforation. There was no evidence of a complicated post-op (operative) course requiring hospitalization and the patient was discharged within 23 hours (on the same day of surgery). Thus, the patient should have had the appendectomy performed under an observation status without acute inpatient admission. 

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 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. 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.   Given this, the patient did not require admission but ambulatory status with observation. 

Furthermore,  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 of the following: Hemodynamic instability; Acute cardiac or peripheral ischemia; Cardiac arrhythmias of immediate concern;  Severe respiratory findings; Severe airflow or ventilation abnormalities, Anasarca; Neurologic abnormalities;  Altered mental status that is severe or persistent, Physiologic disorder (e.g., acute acidosis, thyroid storm, adrenal crisis) that is severe or persists despite observation care,  Suspicion for or diagnosis of abdominal catastrophe, Temperature less than 95 degrees Fahrenheit (35 degrees Celsius) (rectal),  Severe electrolyte abnormalities requiring inpatient care;  Severe anemia; High-risk low platelet count; Disseminated intravascular coagulation; adverse drug or systemic toxin reaction that is severe or persists despite observation; Severe pain requiring acute inpatient management; Inpatient monitoring  needed; Treatment requiring inpatient care; Emergency procedures needed.  Based upon these guidelines this patient should have been observed rather than placed in an acute admission as she did not have any indication as noted above for inpatient stay or prolonged stay. She did not need acute inpatient admission but rather observation status. She presented to the ED, was taken to the operating room, and was discharged on the same day. All of this should have been done in a 23-hour observation setting. She had non-perforated appendicitis and underwent an uneventful laparoscopic appendectomy; and this is an ambulatory procedure as noted by MCG.

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 the inpatient admission is not substantiated.