Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute appendicitis. 
Treatment: Inpatient admission. 
The insurer denied coverage for inpatient admission. 
The denial is upheld. 

According to the documentation submitted, this is a patient with a past medical history (PMHX) of meningioma status post (s/p) resection and hypothyroidism, who presented to the Emergency Department (ED). As per the triage note, the patient presented to the ED with complaint of right lower quadrant (RLQ) abdominal pain associated with nausea and vomiting. The patient was afebrile with stable vital signs. Exam revealed RLQ tenderness on palpation, non-distended with normal bowel sounds in all 4 quadrants without guarding or rebound. Computed tomography (CT) showed uncomplicated acute appendicitis. The patient was admitted to surgery. Surgical history and physical (H&P) noted similar history. White blood cell count (WBC) was 19.03. The patient was booked for laparoscopic appendectomy. 

The patient was taken to the operating room for an uncomplicated laparoscopic appendectomy. There was no perforation noted. Pathology revealed acute appendicitis with peri appendicitis. The disposition was Post-Anesthesia Care Unit (PACU) to home. 

The insurer has denied coverage for the inpatient admission as not medically necessary. In a Final Adverse Determination letter, they stated they are not changing their decision. They noted that the request for inpatient admission was not medically necessary. To approve this service the following criteria must be met: the health data sent did not meet the guide they use called Milliman Care Guidelines (MCG) for M-05 abdominal pain, undiagnosed or CG-AEC Ambulatory surgery exception criteria. There was no data that the condition did not get better after surgery or that the patient needed to stay in the hospital. The stay was denied due to lack of need. A review of the records shows that the patient could have been placed in observation under monitoring, had an evaluation, had testing and been treated symptomatically while awaiting test results. Consultation with other professional could also be done in observation. There was no hemodynamic, pulmonary, neurological, or metabolic reason for acute level of care. 

According to MCG Health Inpatient and Surgical Care 27th Edition Appendectomy, without Abscess or Peritonitis, by laparoscopy ORG: S-175 (ISC) 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 should have been discharged following observation within a 23-hour observation period following surgery. In addition the operative status criteria is ambulatory. 

Furthermore, MCG Health noted in General recovery care 27th edition General admission criteria GRG: CG-GAC (ISC GRG) that admission is indicated for 1 or more of the following: Hemodynamic instability; Acute cardiac or peripheral ischemia; Cardiac arrhythmias of immediate concern; Severe respiratory findings, etc. Based upon these guidelines this patient should have been. The patient had non-perforated appendicitis and underwent an uneventful lap appendectomy; and this is an ambulatory procedure as noted by MCG. 

The inpatient admission 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 laparoscopic appendectomy - all of which should have been done in an observation status. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient admission is not substantiated.