Diagnosis: Digestive System/Gastrointestinal.
Treatment: Inpatient Hospital.

The insurer denied Inpatient Stay.
The denial is upheld.

This patient is a male with no significant past medical history who presented with clinical history, examination, and imaging consistent with acute appendicitis. He was admitted as an acute inpatient and underwent an uncomplicated laparoscopic appendectomy on that day and was discharged to home on the following day.
At issue is the medical necessity of Inpatient Stay.

The health plan's determination of medical necessity is upheld in whole.

The requested health service/treatment of Inpatient Stay is not medically necessary for this patient.
The patient was never unstable, his surgery was uncomplicated, and he stayed 1 night as an inpatient. He required no services to necessitate an inpatient stay. Uncomplicated appendicitis with a laparoscopic appendectomy can be safely performed without an inpatient admission. The patient had an uncomplicated acute appendicitis that was treated with a laparoscopic appendectomy, generally an outpatient procedure. It is well established in the medical literature and in surgical practice that a laparoscopic appendectomy for uncomplicated appendicitis can safely be performed as a same day surgery or outpatient procedure. The American College of Surgeons endorses this perspective.

Therefore, the requested health service/treatment of Inpatient Stay is not medically necessary.