Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain and Testicle Pain.
Treatment: Inpatient Hospital Admission.
The insurer denied: Inpatient Hospital Admission.
The denial is upheld.

The patient is a teenaged male. The patient presented to the hospital with complaints of abdominal pain and right versus left (conflicting notes-see emergency department note) testicular pain. The pain awakened the patient earlier that morning. The patient was sent to the hospital from a physician's office to rule out testicular torsion. 
The patient was evaluated in the Emergency Department where he was examined, underwent laboratory testing, ultrasound, and computed tomography scan. Physical examination 
demonstrated normal vital signs without fever. The patient had mild tenderness in the testicular area bilaterally with suprapubic and right lower quadrant tenderness. Ultrasound of the testicles 
showed no compromise of blood flow and normal positioning of the testes. Ultrasound of the appendix was inconclusive. All laboratory reported values were within normal limits and white blood cell count was not elevated. Neutrophils were not elevated (no left shift). Urinalysis had no abnormalities. Surgical consultation was obtained and computed tomography scan was recommended which showed a normal appendix. It is noted that since arrival in the Emergency Department, the patient was no longer experiencing any pain. The patient was admitted to acute inpatient level of care. The stated reason for admission "was to 
monitor the patient overnight for development of appendicitis." Admission orders included nothing by mouth, intravenous fluids, ondansetron as needed for nausea, and acetaminophen for 
pain. If the pain worsened, a follow-up computed tomography was to be ordered. The next day, the patient did not have recurrent pain. The patient was given regular diet which he tolerated, and he was discharged home. 
The inpatient admission was denied as not medically necessary. This review is for an appeal of the denial of the acute inpatient level of care. The hospital's appeal statement per its agent cites Milliman Care Guidelines (MCG) Health Guidelines for Pediatric Abdominal Pain, Undiagnosed stating (according to the agent) that admission is indicated for evaluation which requires the 
patient to not eat or drink for an extended period. It is further cited that persistent pain coupled with unclear etiology of the pain warranted the admission.

The proposed acute inpatient stay was not medically necessary.

The patient was a teenaged male that presented to the hospital with complaints of abdominal and testicular pain. The patient was sent to the hospital to rule out testicular torsion which was ruled out by ultrasound. White blood cell count was normal without left shift. His computed tomography scan was not suggestive of appendicitis. At the time of admission, the notes mention the patient was no longer symptomatic. On the basis of clinical presentation, computed tomography scan and laboratory 
testing, suspicion for appendicitis should have been low. Based on the information available to the admitting physician at the time of admission, acute inpatient care was not medically necessary. The patient had normal vital signs, no fever and normal white blood cell count. The absence of abdominal pain without 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 (under observation level of care) in a patient not receiving antibiotics with persistent normal white blood cell count. The care rendered did not require acute inpatient level of care.