Diagnosis: Acute Appendicitis

Treatment: inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

This is an adult male with past medical history of gastritis who presented to the emergency department (ED) with abdominal pain. He was afebrile with stable vital signs. Per the History and Physical documentation, he presented with one day history of severe, stabbing, abdominal pain which initially was suprapubic and radiated to the left testicle and was now more localized to the right lower quadrant (RLQ). He had an associated fever overnight. He denied nausea or vomiting or changes in bowel habits. On exam his abdomen was non distended with minimal tenderness in RLQ without rebound or guarding. There was no peritonitis. Labs revealed a white blood cell (WBC) count of 9.84. Computerized tomography (CT) of the abdomen revealed acute appendicitis with the distal appendix in the retrocecal location. The assessment was acute appendicitis, and the patient was admitted to surgery and placed on nothing by mouth (NPO) and given intravenous (IV) antibiotics and IV fluids

The patient was taken to the operating room and underwent an uneventful laparoscopic appendectomy with the findings of a swollen and inflamed retroverted appendix. The postoperative period was uneventful, the patient did well and was discharged on the day of surgery.

The patient had the operative procedure with no complications during or after the procedure that required acute inpatient care. A review of the records showed that the patient could have been placed in observation under monitoring, had an evaluation, had testing and been treated symptomatically while awaiting test results. There was no hemodynamic, pulmonary, neurological, or metabolic reason for acute level of care.

According to MCG (Milliman Care Guidelines) Health Inpatient and Surgical Care 26th Edition Appendectomy, without Abscess or Peritonitis, by laparoscopy optimal recovery course includes floor to discharge with the following milestones completed: hemodynamic stability; procedure completed; no evidence of post op or surgical site infection; diet tolerated; pain absent or managed; no evidence of ileus or bowel obstruction; oral medications and oral diet.

Based upon the records provided, the patient reached these milestones, and could have been discharged following observation within a 23-hour observation period following surgery. Furthermore, according to MCG, the operative status criteria is ambulatory.

This patient could have been observed rather than placed in an acute admission as he did have any indication for inpatient stay but rather observation. Non perforated appendicitis and lap appendectomy is an ambulatory procedure as the insurer noted.

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for an inpatient admission is upheld. Medical Necessity is not substantiated.