Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute appendicitis

Treatment: Inpatient admission 

The insurer is denied coverage for inpatient admission.   

The denial is upheld. 

According to the patient's medical record, this was then a female who presented to the Emergency Department (ED) with complaints of right lower quadrant (RLQ) abdominal pain for days prior to presentation, vomiting and diarrhea. The patient was admitted and presented with the complaint of abdominal pain. The patient was afebrile. The patient complained of right thigh/groin pain for 1 week. The patient reported that the pain was constant but resolved in the ED. The patient reported vomiting prior to this ED arrival with no subsequent vomiting until the day prior to this ED arrival.  The patient also reported having 2 episodes of diarrhea, the day prior and the day of the ED arrival. The patient denied fever or chills. On exam in the ED, the patient had an unremarkable abdominal exam. The patient's abdomen was noted to be non-tender and soft. The plan was to rule out an incarcerated hernia with SBO although the ED doctor noted that this was unlikely given no pain now and no palpable groin mass. The patient's white blood cell (WBC) count was 3.6. The patient's computed tomography (CT) scan of the abdomen was indicative of early changes of acute appendicitis. The patient was taken to the Operating Room (OR) and underwent laparoscopic appendectomy with lysis of adhesions. The operative findings included acute suppurative appendicitis with appendix stuck to the anterior abdominal wall. The patient was received from the OR by the floor nurse. The patient had stable vital signs and was started on clear liquid diet postoperatively. The progress note indicated that the patient was stable with stable vital signs and with the plan to advance the diet and discharge home.

Based upon MCG guidelines for Appendectomy, without Abscess or Peritonitis, by laparoscopy ORG: S-175 (ISC), the optimal recovery course includes floor to discharge with the following milestones completed: hemodynamic stability; successfully uncomplicated lap appendectomy; no evidence of postop 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 inpatient admission. 

Literature review supports that this patient's inpatient admission was not medically necessary. The patient could have been cared for at a less intensive setting, such as observation level of care. The patient presented to the hospital and was admitted and underwent laparoscopic appendectomy in the morning. The procedure was noted to be uncomplicated, and the patient was doing well post-operatively. There was no sign of generalized peritonitis or evidence of perforation or abscess. The patient was ambulating and had stable vital signs. The patient could have been discharged home following a brief period of observation. The patient did not need to be kept under an acute admission. 

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

Based on the above, the medical necessity for the inpatient admission is not substantiated.  The insurer's denial should be upheld.