Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

This patient is an adult female who presented to the emergency department with the complaint of abdominal pain. Her past 
medical history included sleeve gastrectomy, sickle cell disease with leukopenia, and prior Cesarean section. Examination revealed abdominal tenderness in the right lower abdomen. The 
patient's vital signs noted a normal temperature at the time of presentation. The heart rate was normal at 69 beats per minute. White blood cell (WBC) count was 2.8 thousand (K). Abdominal 
computed tomography (CT) scan was completed and showed findings consistent with acute appendicitis. The patient was admitted to the hospital and was started on intravenous antibiotics. Surgical consultation was obtained. On day #2 the patient reported feeling worse with continued right lower abdominal pain. She underwent laparoscopic (robotic assisted) appendectomy. Operative findings included an acutely inflamed appendix. The operation was completed without complication. The patient was monitored following surgery and remained stable. The post-surgical note indicates that the patient was without new complaint. She had normal vital signs following surgery. She was started on a diet following surgery. She was discharged from the hospital on the next day following the initial surgical recovery with instructions for surgical follow-up. 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 without an inpatient status. This letter references Milliman Care Guidelines (MCG) criteria.

The inpatient care was not medically necessary for this patient.

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 submitted medical records do not indicate that there were hemodynamic, pulmonary, neurological, or metabolic reasons for an acute inpatient level of care. Vital signs were normal at the time of emergency department presentation. The 
patient's evaluation with history and physical exam and computed tomography (CT) scan supported the indication for appendectomy. There were no complications of surgery performed the next day and this operation is typically performed without need for full inpatient admission. 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 emergency department assessment, provision of intravenous fluid and 
antibiotics, surgical consultation, surgery to remove the appendix, and post-surgical monitoring. This patient was clinically stable at the time of presentation to the emergency department, she remained stable throughout the perioperative period and was able to be discharged from the hospital following an uncomplicated initial recovery. 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.