Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute appendicitis

Treatment: acute inpatient hospital stay

The insurer denied coverage for acute inpatient hospital stay. The denial is overturned.

This patient is a male with no past medical history who presented to a hospital with complaints of right lower quadrant (RLQ) pain since the day before presenting. As per the triage note the patient had chief complaint of abdominal pain. He was afebrile. As per the HPI, the patient reported nausea but denied any vomiting. On exam he had RLQ tenderness to palpation with rebound and guarding. The patient had a Rovsing's and Psoas sign present. The patient was admitted to surgery and was started on IV antibiotics and made NPO. WBC was 9.98. Ultrasound of the abdomen read was non visualization of the appendix. CT of the abdomen read indicated acute appendicitis with moderate to severe adjacent inflammatory changes but without definite perforation.

Based upon the records provided, the patient did require acute inpatient stay with hospital admission as the patient could not have been cared for based upon a 23 hour observation admission given that the patient had postop flash pulmonary edema and needed inpatient monitoring. The patient was admitted and was taken to the operating room for lap appendectomy. He underwent an uneventful lap appendectomy, however he had an episode of hypoxia with flash pulmonary edema requiring inpatient monitoring and supplemental oxygen; and this could not have been done on an observation status. The patient did need further acute care following the appendectomy. Although he did not have any sign of an abscess or perforation at the time of surgery, he did develop flash pulmonary edema with hypoxia. He was observed in PIMU and discharged the following day after stabilization. Medical necessity of acute inpatient hospitalization was warranted, as the patient was not stable post op and could not have been discharged within a 23 hour observation period.  There was evidence of a complicated post op course requiring hospitalization with the flash pulmonary edema. Therefore, the patient required inpatient admission and observation.

As per MCG- Health Inpatient and Surgical Care 24th Edition Appendectomy, uncomplicated, open or laparoscopic ORG: P-20 (ISC) the Operative Status Criteria is ambulatory with the goal length of stay is ambulatory. Extended Stay as defined by Minimal (a few hours to 1 day), Brief (1 to 3 days), Moderate (4 to 7 days), and Prolonged (more than 7 days) may be needed for: failure to achieve discharge status; prolonged fever and prolonged fever may require longer observation in hospital on parenteral antibiotics and one can expect brief stay extension; complicated appendicitis with discovery or development of generalized peritonitis or intra-abdominal abscess may require longer observation on parenteral antibiotics; complications such as wound infection, intra-abdominal abscess, fecal fistula, pylephlebitis, and intestinal obstruction may occur and require continued observation or reoperation and one can expect brief to moderate stay extension; prolonged ileus with prolonged ileus may delay initiation of feeding and one can expect brief stay extension; or postoperative bleeding may require reoperation and one can expect brief stay extension.  This patient did require extended stay as he did not achieve discharge status and required postop monitoring given the hypoxia. 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for the acute inpatient hospital stay is substantiated.  The insurer's denial is overturned.