Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis

Treatment: Inpatient admission 

The insurer denied the inpatient admission.

The denial was upheld.  

This is a male patient with a history of asthma, allergic rhinitis, and obesity. He presented to the Emergency Department (ED) with complaints of intermittent abdominal pain, diarrhea and nausea; he rated her pain 10/10 in severity. The night prior to ED presentation, the patient reported that his pain was severe and that he was having difficulty urinating. He also reported that he had attempted to drink some water but was unable to keep the liquid down.  The patient's physical examination revealed an obese abdomen with diffuse tenderness to palpation with involuntary guarding; there was no rebound. The patient had a heart rate of 120.  The treatment plan included laboratory studies, and pain control with morphine and Zofran as needed.  The patient's laboratory studies revealed a white blood cell (WBC) count of 18.7, platelets 441, bilirubin 1.5, and C-reactive protein 1.9. The patient's urinalysis revealed trace leukocytes esterase and small bilirubin. A computed tomography (CT) scan of the abdomen revealed a distended gallbladder, atrophic left kidney, hepatic steatosis, and hepatomegaly. The patient was ordered nothing by mouth (NPO) status.  The patient's ultrasound was unable to visualize the appendix; however, there were no gallstones.  The patient was given intravenous famotidine and was to be reassessed.  The patient's CT scan showed that the appendix was at the upper limit of the diameter.  The patient still had pain and tenderness in the right lower quadrant and left upper quadrant.  The patient was admitted with diagnoses of abdominal pain, vomiting, rule out appendicitis.  The patient was stabilized and discharged home.

According to literature review, patients that need hospitalization are those with the following signs and symptoms:  Significant volume depletion/dehydration, altered mental status, significant rectal bleeding, severe unrelenting abdominal pain, comorbidities such as HIV and diabetes (immunocompromised status), age >=65 years, recent hospitalization or antibiotics, pregnancy, or weight loss.  However, in this case, there was no dry oral mucosa, no hypotension, no fever, no low oxygen (O2) saturation, no rebound guarding, no abdominal rigidity requiring hospital admission rather than ambulatory setting such as observation. The patient's lab data showed no electrolyte discrepancy, acid/base derangement, or renal impairment (i.e., no elevated BUN or creatinine) that needed acute hospital inpatient admission status.  The patient had a white blood cell (WBC) count elevation of 18.7 and CRP elevation of 1.9 (<0.8), and elevated total bilirubin of 1.5 (1.2) but these values were nonspecific and could be seen in cases of gastroenteritis.  The patient's computed tomography (CT) scan and ultrasound were unremarkable. The patient's treatment that included hydration, intravenous pain medications, and monitoring could have been safely provided during a period of observation. Thus, inpatient admission was not medically necessary for this patient. 

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

The carrier's denial of coverage for the inpatient admission should be upheld.  The medical necessity is not substantiated.