Diagnosis: Appendicitis
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient presented to the hospital with a history of progressively worsening abdominal pain of 1-day duration. Comorbid health conditions included hyperlipidemia. His evaluation included a physical exam, labs, and computed tomography (CT) scan. He was without a fever at the time of presentation. Lab data identified a white blood cell count (WBC) count of 7.6 thousand (K). The CT scan yielded the diagnosis of appendicitis. Treatment was initiated with intravenous (IV) fluid and antibiotics. A surgical consultation was obtained.

The patient underwent a laparoscopic appendectomy. The clinical notes and the anesthetic record indicate an uncomplicated appendectomy with findings of acute appendicitis without abscess. He was provided IV fluids and perioperative antibiotics. Vital signs remained normal throughout the hospitalization without a fever. The diet was advanced and pain management was converted to oral medications. He was discharged home following the initial recovery period.

At issue is the medical necessity of an inpatient stay.

Inpatient stay was not medically necessary for this patient.

This patient presented with abdominal pain. The evaluation with examination, lab data, and CT scan supported the diagnosis of appendicitis. The initial treatment appropriately included nothing by mouth (NPO) status, IV fluid, and the appendectomy. The early post-surgical course was uncomplicated and the patient was hemodynamically stable and tolerating a diet on the first post-surgical day.

The submitted clinical documentation does not support the need for an inpatient admission for this patient. The patient presented with abdominal pain and underwent an uncomplicated appendectomy. A lower level of care would have satisfactorily provided for the care provided and would have been consistent with the accepted standard of medical care.

The patient was clinically stable at the time of presentation and remained so during the course of care. Presurgical assessment, serial examination, operative treatment and post-surgical monitoring could have been provided at a lower level of care than inpatient.

Generally accepted guidelines state that the goal length of stay is ambulatory or 1 day postoperative. These guidelines indicate that in the absence of hemodynamic instability, sepsis or toxicity, significant electrolyte imbalance, bleeding, gastrointestinal (GI) obstruction or surgical complications, the procedure may be performed with an ambulatory level of care. In this case, the patient tolerated oral hydration, diet and medication and pain was well controlled.