Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Appendicitis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

 This is a child who presented with abdominal pain and fever to Maimonides Medical Center Emergency Room. Computed tomography (CT) was concerning for acute appendicitis and the child was admitted to Pediatric surgery service for management of acute appendicitis with intravenous (IV) antibiotic and possible interval appendectomy upon reevaluation.

On admission the child reportedly had fever previous days, periumbilical abdominal pain previous 3 days, post prandial emesis 4 times in the last 2 days. Motrin provided minimal relief.
In the emergency department (ED) vital signs were: Temperature 100.1 degrees F, Heart Rate 147  and Blood Pressure 100/67. Physical examination revealed a well appearing child, well hydrated, with diffuse abdominal pain Right greater than (&gt;) Left side with guarding and tenderness on palpation. He was worked up for appendicitis and administered intravenous fluid (IVF) bolus, Zofran and Heparin.

The Surgical physician noted that the patient appears comfortable, Abdomen non-distended with mild tenderness to palpation in right lower quadrant (RLQ) and left lower quadrant (LLQ), no rebound or guarding.

Labs showed: white blood cells (WBC) 15.4, Hemoglobin and Hematocrit (H/H) 12.8/38.9, platelets 329, elevated neutrophils 75.1 and monocytes 10. Chemistry was within normal limits. Liver function tests (LFTs) showed alanine transaminase (ALT) 29. C-reactive protein (CRP) elevated 2.004. The respiratory viral panel was NEGATIVE. Vitals remained stable. Abdominal ultrasound showed no Right Upper Quadrant (RUQ) abnormality. The appendix is not identified. Correlate with cross-section imaging Computed tomography (CT) showed elongated tortuous appendix and suspected mild tip appendicitis with numerous prominent lymph noted in the RLQ mesentery.
Patient was admitted for non-operative management with intravenous (IV) Cefoxitin every 6 hours, pain control, nothing by mouth (NPO), IV Fluid with reassessment for possible interval appendectomy.

The patient was noted as globally improved since admission on IV antibiotics. He was complaining of mild diffuse abdominal pain, waxing and waning. Tolerated breakfast without nausea or emesis. The attending physician (pediatric surgery) stated that given atypical presentation for appendicitis, he was admitted and treated nonoperatively with IV antibiotic. Since admission, the patient has been afebrile with improvement of abdominal pain. Tolerating regular diet. For possible discharge later in the day or next day depending on patient's progress. Patient was discharged on Augmentin.


There is emerging evidence supporting non-operative treatment of acute appendicitis with IV antibiotics for at least 24hrs with minimum 24hrs of inpatient observation pending clinical improvement and oral (po) tolerance (6). 

This child was admitted and managed for presumed acute appendicitis (based on history, physical exam findings, labs and result of abdominal CT) per recent evidence and proposed guidelines. He was started on intravenous (IV) antibiotic and admitted with consideration for possible surgical appendectomy pending clinical course. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for inpatient hospital admission is substantiated.