Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute appendicitis
 
Treatment: Inpatient admission

The insurer denied coverage for inpatient admission. The denial is upheld. 

This patient is a female with past medical history of asthma who presented to the Emergency Department (ED) with complaints of worsening abdominal pain for one week associated with chills.  The patient was seen with lower abdominal pain which was getting worse.  She had her period the week prior.  She denied nausea or vomiting.  She was afebrile.  Her abdomen was soft with right lower quadrant tenderness (RLQ) tenderness at McBurney's point without rebound or guarding.  There were no peritoneal signs.  CT of the abdomen revealed minimal appendiceal wall thickening and an early acute appendicitis could not be ruled out.  White blood cell (WBC) count was 8.0.  The impression of the Surgery consultant was that this was clinically suspicious for acute appendicitis but there was no leukocytosis.  The plan was for Transvaginal ultrasound (TVUS).  TVUS was done and there were no acute findings.  The abdomen was persistently tender in the right lower quadrant (RLQ).  The plan was to admit to Surgery and have the patient placed in a pre-operative mode.
Progress note on the day after presentation revealed the patient was afebrile.  The Attending noted the plan for laparoscopic appendectomy.  The patient was taken to the operating room on the day after presentation for a laparoscopic appendectomy.  Findings included acutely inflamed edematous thickened distal appendix.  There was no indication that there was perforation or an abscess. Post-operatively a specified date it was noted the patient was stable and tolerating clear liquid diet and the patient was cleared for discharge to home with follow up with general surgery outpatient clinic.
Based upon MCG guidelines, Inpatient and Surgical Care 23nd Edition; Appendectomy, without Peritonitis, by Laparoscopy ORG: S-175 (ISC) optimal recovery course includes floor to discharge with the following milestones completed: procedure completed; no evidence of ileus or bowel obstruction; fever absent; diet tolerated; pain absent or managed, oral medications and oral diet.  Based upon the records provided, the patient reached these milestones, and should have been discharged within a 23-hour observation period.  Furthermore, according to MCG, the goal length of stay is ambulatory or 1 day postoperative.  The operative status criteria include ambulatory for most patients and inpatient for patients with severe systemic illness (e.g., sepsis), poorly controlled co morbidities (e.g., COPD, chronic heart failure), or complications from procedure (e.g., infection, bleeding) that require more than 24 hours of postoperative care.  Milliman notes that most patients can be treated on an ambulatory basis.

This patient did not have any factors 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) and the patient should have been discharged within 23 hours and did not require acute inpatient setting.  

To summarize, the acute level of care, inpatient admission was not medically necessary. Based upon these findings the health care plan did act reasonably and with sound medical judgment. 

The carrier's denial of coverage for the inpatient admission for acute level of care is upheld.  The medical necessity is not substantiated.