Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Epigastric pain
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld

The patient is a female that presented with complaint of a three-day history of epigastric pain and a one-day history of diarrhea. The patient had vomited once the previous day. The patient has a history of gastroesophageal reflux disease for which she takes medication. The previous day, the medication did not relieve the pain. 

The patient's physical examination revealed mild peri-umbilical tenderness. The patient had normal vital signs and was without fever. White blood cell count was not elevated (4900) with a low absolute neutrophil count and mildly elevated lymphocytes.  Alkaline phosphatase was mildly elevated to 272. All other labs were within normal limits. Ultrasound was non-diagnostic and the patient underwent computed tomography (CT) scan of the abdomen and pelvis. Computed tomography scan showed a prominent tip of the appendix measuring six millimeters with trace fluid in the lumen. The impression was "possible early tip appendicitis." The patient was also noted to be moderately constipated. 

Following the computed tomography scan, the patient was ordered for regular diet and was eating a sandwich. The patient was admitted to acute inpatient level of care at 15:41. The stated reason for admission was concern for acute appendicitis. The patient was not started on and did not receive antibiotics during the hospitalization.  Admission orders included regular, intravenous fluids, acetaminophen and ibuprofen for pain, and follow-up complete blood count monitoring. 

On hospital day #2 the patient was improved but still complained of abdominal pain. She was feeling well overall. Physical examination demonstrated a small reducible umbilical hernia and mild tenderness in the peri-umbilical region. Regular diet was continued. No follow-up laboratory results are included in the clinicals.

The patient was discharged with diagnosis of abdominal pain possibly due to constipation. The patient still complained of unchanged mild peri-umbilical pain.

The acute inpatient level of care was denied as not medically necessary. The rationale for the denial is that the testing and monitoring could have been done with the patient placed under observation with symptomatic treatment while awaiting test results. Based on the test results, the patient could have been discharged from observation with ambulatory plan of care.

The hospital through its agent, has appealed the denial of the acute inpatient level of care stating acute inpatient admission was warranted due to presenting factors of abdominal pain and diarrhea, tenderness on exam, computed tomography findings of possible tip appendicitis, and the patient's young age. Other cited factors were surgical consult, trending of labs and skilled assessments. The persistence of symptoms and unclear etiology of pain are cited as factors which made acute inpatient admission medically necessary.

No, the proposed treatment, acute inpatient stay, was not medically necessary.
The patient is a female that presented with complaints of abdominal pain and diarrhea. White blood cell count was low normal at 4,900 without left shift. COVID testing was negative. Clinical presentation, computed tomography  scan and laboratory testing were not consistent with appendicitis. Computed tomography showing a six millimeter tip of the appendix with trace luminal fluid and no surrounding inflammation essentially ruled out appendicitis. The patient was given a regular diet (despite the appeal stating the patient was nothing by mouth [NPO]) and was admitted without antibiotics. No repeat laboratory testing was done and the patient reported improved pain the following morning. The care rendered did not require acute inpatient level of care and the two-day hospitalization was not indicated. The patient had normal vital signs, no fever and normal white blood cell count. Persistent abdominal pain with equivocal at best findings on computed tomography did not require acute inpatient level of care. If the patient in fact had appendicitis, that would have been evident the following day with the patient not receiving antibiotics and taking a regular diet.  The patient could have been cared for at a lower level of care. 

It is agreed that the acute inpatient level of care was not medically necessary and that the testing and monitoring rendered could have been done with the patient placed under observation with symptomatic treatment while awaiting test results and that based on the test results, the patient could have been discharged from observation with ambulatory plan of care.

Yes, the health plan's denial of the acute inpatient level of care was reasonable. The denial decision was appropriate and without compromise of the best interests of the patient. The care could have been rendered at a lower level of care without compromise of the quality of care rendered or patient safety.
The patient is a female that presented with a three-day history of abdominal pain and a one-day history of diarrhea. Vital signs were within normal limits. Laboratory testing showed a normal white blood cell count. The patient underwent computed tomography of the abdomen for diagnostic workup prior to the decision to admit to the patient to surgery. Computed tomography identified a normal appendix with a prominent tip measuring six millimeters which would be considered normal (abnormal is seven millimeters). There were no reported secondary signs of appendicitis or any other intra-abdominal pathology. Moderate constipation was noted. The decision was made to admit the patient. 

Based on the duration of symptoms, if appendicitis was suspected, there would have been more definitive findings. In addition, the patient did not receive antibiotics and was ordered for regular diet. She was noted to be eating a sandwich before she left the Emergency Department.  The patient was treated with oral pain medication and daily examination. No follow-up labs were ordered or documented. Even if the child did have uncomplicated appendicitis and required laparoscopic appendectomy, this would be considered an ambulatory procedure by standard of care for pediatric appendicitis. 

The child continued to complain of abdominal pain which continued on the day of discharge. The care the patient received did not require acute inpatient level of care. The care the patient would have received at a lower level of care would have and could have been identical to that which she received. A lower level of care would not reasonably be expected to adversely affect the quality of care rendered or patient safety.  

In response to the hospital's appeal that the patient required inpatient level of care, its agent states the acute inpatient admission was warranted due to presenting factors of abdominal pain and diarrhea, tenderness on exam, computed tomography findings of possible tip appendicitis, and the patient's young age. None of these factors required acute inpatient level of care. Also cited is surgical consult, trending of labs and surgical consultation. However, there are no orders for trending of labs and no record of follow-up labs. Surgical consult in the Emergency Department noted equivocal findings for appendicitis and recommended admission for observation. The persistence of symptoms and unclear etiology of pain are cited as factors which made acute inpatient admission medically necessary. No reasons are provided in the appeal as to why the patient could not have been treated at a lower level of care such as assessment in the Emergency Department or observation level of care.