Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.

The denial is upheld.  

This female patient has a past medical history of anxiety, asthma, and seizures who presented to the Emergency Department (ED) with complaints of abdominal pain. There was some vomiting. The patient denied fever or chills. The patient had a temperature of 100.2 with stable vital signs. The exam revealed that the abdomen was flat with abdominal tenderness in the right upper quadrant (RUQ), right lower quadrant (RLQ) and epigastric area. There was no costovertebral angle tenderness. The patient's white blood cell (WBC) count was 3.4 with Beta HCG of 6. Pelvic ultrasound showed pregnancy of undetermined location. The patient's computed tomography (CT) scan of the abdomen showed acute appendicitis. Findings were concerning for multifocal pneumonia, inclusive of but not specific to COVID infection. The plan was intravenous (IV) Zosyn. The patient's SARS COVID test was positive. The assessment was appendicitis. The obstetrics/gynecology (OB/GYN) noted that the patient's Beta HCG was 6 and that ultrasound would be of limited utility to determine location of pregnancy. At the time of surgery there was no sign of ectopic pregnancy. An uneventful laparoscopic appendectomy was performed with findings of non-suppurative, non-perforated appendicitis. Post-operative surgery note indicated white blood cell (WBC) of 2.2. The patient was tolerating a regular diet and had stable vital signs. The patient continued to do well. The patient did not have any symptoms for COVID even though the patient was found to be positive. 

The patient did not have any factors that required hospitalization, or any other factors to require prolonged hospitalization (e.g., ileus, postop bleeding, and signs of peritonitis, wound infection, or complication). She did not have any comorbidity that required treatment that would have extended her stay. The patient was asymptomatic from COVID and did not require inpatient admission for this. 

Based upon MCG guidelines, this patient could have been observed rather than admitted to inpatient status. The patient did not have a temperature or sepsis. She had appendicitis and underwent an uneventful lap appendectomy. She was kept an additional day because of her being COVID positive. 

The surgical progress note indicated that the patient could have been discharged should have been discharged later in the evening within an observation period. She was kept in the hospital because she tested COVID positive although asymptomatic. The patient did well postoperatively, had stable vital signs, and was tolerating diet. The patient did not require an acute inpatient admission, as she did not have any complications from the surgery that warranted inpatient level of care. The patient's testing COVID positive was not an indication for this patient to be admitted. The laparoscopic appendectomy was uneventful and there was no perforation or purulent fluid/ abscess. There was no evidence of a complicated postoperative course requiring hospitalization. Thus, the patient should have had the appendectomy performed under an observation status.

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

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