Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis
 
Treatment: Inpatient Admission

The insurer denied the Inpatient Admission. The denial was upheld.   

This is a male patient who presented to the Emergency Department (ED) with complaints of right sided abdominal pain for three days. It was reported that he had been seen at his primary care physician's office earlier that day with the same complaints; a computed tomography (CT) was performed at that time. A physical examination was performed; his abdomen was noted to be soft and non-distended. Laboratory work up was done revealing a white blood cell (WBC) count of 5.9. Surgery consulted on the patient. He was made nothing by mouth (NPO). Intravenous (IV) antibiotics were administered. It was determined that he had an acute appendicitis; a laparoscopic appendectomy surgery was planned for the next day.  The following day the patient was re-evaluated, the surgery was canceled due to that the patient's blood work not demonstrating signs infection. He was given a regular diet with tolerance. He was discharged home with outpatient follow up instructions. 

Based upon the records provided, the patient did not require acute level of care as he could have been cared for based upon an observation admission.  The patient presented to the hospital with the history of an outside CT scan showing appendicitis.  His WBC was normal.  He had minimal pain on physical exam.  He was afebrile and denied nausea or vomiting.  He was treated with antibiotics with the plan for OR in the morning for a laparoscopic appendectomy.  However by the morning, the pain had improved and the labs did not confirm an infectious process. The decision was made to cancel surgery, advance the diet and discharge the patient.  All of this could have been done on an observation status.

According to MCG Inpatient and Surgical Care 23rd Edition Abdominal Pain, Undiagnosed ORG: M-05 (ISC) admission may be indicated for 1 or more of the following: Surgery needed that cannot be performed on ambulatory basis; Peritoneal signs present;  Evaluation requires patient to not eat or drink for extended period (e.g., more than 24 hours; Hemodynamic instability;  Severe pain requiring acute inpatient management; Identification of etiology or finding that requires inpatient care (e.g., aortic dissection, free air, bowel ischemia, visceral organ torsion; Signs of intestinal obstruction; Suspected toxic megacolon; Bacteremia; Severe electrolyte abnormalities requiring inpatient care; Inability to maintain oral hydration (e.g. needs IV fluid support) that persists after emergency department and observation are treatment; Percutaneous or open drainage (e.g., abscess, biliary tract) procedures; Parenteral nutrition regimen that must be implemented on inpatient basis; other condition, treatment, or monitoring requiring inpatient admission.  The goal length of stay is ambulatory or 1 day. 

In this case, there was no indication for admission given the guidelines above as this patient could have been treated in ambulatory/observation status. Based upon these findings, the health care plan did act reasonably and with sound medical judgment and in the patient's best interest.

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