Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute appendicitis, laparoscopic appendectomy
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient hospital admission.
The denial is upheld.

This patient is a previously healthy adult male who presented to the emergency department (ED) with the complaint of abdominal pain of one-day duration. Examination revealed abdominal tenderness in the right lower quadrant. Vital signs identified a normal temperature at the time of presentation. The heart rate was 89 beats per minute. The white blood cell (WBC) count was elevated at 14.7 thousand (K). Abdominal computed tomography (CT) scan was completed showing findings consistent with acute appendicitis. Surgical consultation was obtained. The patient was admitted to the hospital and was started on intravenous (IV) antibiotics. The patient underwent laparoscopic appendectomy. The operation was completed without complication. The patient was monitored following surgery and remained stable. The next day Progress Note states that the patient was without new complaint. He had normal vital signs. The patient was discharged from the hospital following the initial surgical recovery with instructions for surgical follow. The health plan rationale for denial is that there is no documentation of need for an inpatient level of care and the care rendered could have been provided without full admission to the hospital. The care provided could have been rendered with an observation status. This letter references Milliman Care Guidelines (MCG) Appendectomy with abscess or peritonitis by laparoscopy.

The inpatient care was not medically necessary.

The health plan rationale for denial is that there is no documentation of need for an inpatient level of care and the care rendered could have been provided without full admission to the hospital. There were no hemodynamic, pulmonary, neurological, or metabolic reasons for an acute inpatient level of care. Vital signs were normal. There were no complications of surgery, and this operation is typically performed without need for full inpatient admission. This is supported by the submitted medical records. Inpatient care for this patient was not medically necessary based on the standard of care. The care provided during this time could have reasonably and appropriately been provided with a lower level of care. A lower level of care would have provided for the ED assessment, provision of IV fluid and antibiotics, surgical consultation, surgery to remove the appendix and monitoring. This patient was clinically stable at the time of presentation to the ED, he remained stable throughout the perioperative period and was able to be discharged from the hospital following an uncomplicated initial recovery on the first post-surgical day. Generally accepted medical standards indicate that in the absence of hemodynamic instability, sepsis or toxicity, significant electrolyte imbalance, bleeding, gastrointestinal obstruction or surgical complications, treatment as provided in this case could be provided without an inpatient level of care. In this case, the patient tolerated oral hydration following surgery. A lower level of care would have appropriately provided for treatment and monitoring. Inpatient care was not required or medically necessary in this case per generally accepted medical standards.