Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute Appendicitis. 
Treatment: Inpatient Admission. 

The insurer denied coverage for inpatient admission. 

The denial is upheld. 

The patient is female with no past medical history who to the emergency room (ER) for mid epigastric pain. She was admitted to pediatric unit for acute appendicitis. The triage nurse noted the patient was transferred from another hospital for appendicitis. The note indicated that the ultrasound could not visualize the appendix and the CT  (computed tomography) was questionable for appendicitis. The patient denied fever, nausea, or vomiting. The abdomen was soft but tender to palpation. The patient was admitted. 

As per the ED (emergency department) provider's note, the patient was transferred from another hospital for further management of acute appendicitis. The patient began with pain yesterday in the morning and it worsened throughout the day. The patient denied fever or vomiting. Exam revealed the abdomen to be soft, non-distended, positive for rebound and guarding. There was tenderness over McBurney's point. The pediatric H and P (history and physicial) indicated a similar history and noted the WBC (white blood cell) of 13.92 and CT of the abdomen which showed dilated appendix with surrounding fluid consistent with appendicitis. 

She underwent an uneventful lap appendectomy with the findings of a non-perforated acute appendicitis. Path revealed acute appendicitis. The patient did well post op and was discharged later in the day with follow up as an outpatient. 

As per MCG (Milliman Care Guidelines)- Health Inpatient and Surgical Care 26th Edition Appendectomy, uncomplicated, open or laparoscopic, 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 ...that required hospitalization, or any other factors present that would have required prolonged hospitalization (e.g., ileus, postop bleeding, and signs of peritonitis, wound infection, or complication), or any co morbidities that required treatment at the time that would have extended her stay. The patient should have had the procedure done under ambulatory/observation status as she did not require an acute inpatient setting. 

The inpatient admission stay was not medically necessary at the acute inpatient level and denial for hospital admission should be upheld. The patient was admitted and underwent an uneventful lap appendectomy- all of which could have been done in an observation status. She did not need an acute admission.  The medical necessity of the inpatient admission was not justified, as observation status was sufficient. 

The health care plan did act reasonably and with sound medical judgment. 

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