Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute appendicitis. 
Treatment: Hospital admission. 

The insurer denied coverage for the hospital admission. 

The denial is upheld. 

This is a male patient with past medical history of hypertension (HTN) who presented to the Emergency Department (ED) with complaints of right lower quadrant (RLQ) abdominal pain. The patient denied Murphy or Rovsing's sign. The patient was noted to be afebrile in the ED with stable vital signs.  A computed tomography (CT) scan of the abdomen revealed acute appendicitis with associated inflammatory changes and no evidence of drainable fluid collection or free air. The patient was admitted with the diagnosis of acute appendicitis and treated with intravenous (IV) fluids and IV antibiotics. As per the general surgery note, the patient had a 3 day history of abdominal pain that was noted to be sharp and localized to the peri umbilical area. They noted that the patient denied fever, chills, nausea, vomiting, diarrhea or constipation. The patient's white blood cell (WBC) count was 11.1. The patient was afebrile with the abdominal exam revealing a soft, non-distended abdomen with focal tenderness to palpation. The assessment was acute appendicitis, and the plan was for laparoscopic (lap) appendectomy. The patient underwent a lap appendectomy and the surgery was uneventful. The pathology revealed acute appendicitis and peri-appendicitis with changes consistent with perforation; grossly perforation was not identified. Post-operatively the patient was able to tolerate a diet, ambulate, void and have a normal bowel function. His pain was well controlled with oral medication. 

Based upon Milliman Care Guidelines (MCG) Health Inpatient and Surgical Care 25th Edition Appendectomy, with Abscess or Peritonitis, by Laparoscopy, 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 could have been discharged following observation within a 23-hour observation period following surgery. 

This reviewer agrees with the insurer that the patient did not require acute inpatient admission as the patient should have been cared for based upon an observation admission. The patient presented to the hospital and was taken to surgery the next day. He did well post operatively, had stable vital signs, and was tolerating his diet. He did not require an acute inpatient admission but rather observation status as he did not have any complications from the surgery that warranted inpatient care. The lap appendectomy was uneventful and there was no gross perforation or purulent fluid/ abscess noted in the operative report. In fact, pathology did not find any gross perforation. There was no evidence of a complicated post-operative course requiring hospitalization. Thus, the patient should have had the appendectomy performed under an observation status without an inpatient admission. 

The inpatient admission stay was not medically necessary at the acute inpatient level and denial for hospital admission should be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The insurer's denial of coverage for the hospital admission is upheld. Medical necessity is not substantiated.