Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute appendicitis. 
Treatment: Full hospital admission. 
The insurer denied coverage for the full hospital admission. 
The denial is upheld. 
 
According to the documentation submitted, this adolescent presented to the Emergency Department (ED) on with the complaints of right lower quadrant pain for a few hours. As per the ED provider note the patient presented with onset of right lower quadrant (RLQ) and pelvic pain. The patient was afebrile with stable vital signs. On exam the patient had RLQ tenderness without rebound or guarding. General surgery was called in consultation. White blood cell count (WBC) was 9.3k (thousand). Computed tomography (CT) scan of the abdomen at showed peri appendiceal enhancement and early appendicitis could not be excluded.

Surgery saw the patient and noted the history of RLQ pain since 6 PM the night before. The patient denied fever, or chills. The past medical history (PMHX) is significant for an eating disorder. The assessment was RLQ and the plan was nothing per oral (NPO), IV (intravenous) fluid and no antibiotics at this time. If symptoms worsen without clear etiology the plan would be diagnostic laparoscopy. 

The patient was taken to the operating room. The procedure performed was lap (laparoscopic) appendectomy. The finding was early acute appendicitis. There were no complications noted. 

The patient did well and was discharged later that day to home. 

The insurer has denied coverage for a full hospital admission. In their Final Adverse Determination letter, they stated they are not changing their decision. They noted that the doctor wanted a full hospital admission after surgery to remove the appendix. The plan clinical criterion considers a full hospital admission medically necessary when there are serious problems such as a hole in the bowel (perforation). The information they have does not show that they have this or other severe problems. For this reason, the request for full admission is denied as not medically necessary. The decision was made based upon Milliman Care Guidelines (MCG) called Appendectomy, without abscess or peritonitis, by laparoscopy, pediatric (ORG: P-20). 

The hospital is appealing and noted that the admission was medically necessary and documentation. Past medical history (PMHX) of postural orthostatic tachycardia syndrome (POTS), eating disorder presented to the Emergency Department (ED) with new onset of right lower quadrant (RLQ) and right pelvic pain that awoke from sleep. The pain worsened and the patient was brought to the ED for evaluation. The patient reported nausea and loss of appetite as well. On exam the patient had right pelvic and suprapubic tenderness. Pelvic ultrasound was unremarkable. Computed tomography (CT) scan of the abdomen showed per appendiceal enhancement and early appendicitis could not be excluded. Surgical consult was obtained. The patient was given intravenous (IV) Zosyn, and Zofran. It was determined by the Emergency Department (ED) and general surgeon that due to early appendicitis, admission was required for further evaluation and treatment. Inpatient care included nothing per oral (NPO), IV fluids. The patient continued to complain of pain. Abdominal exam revealed increased tenderness to the right lower quadrant (RLQ). The patient was taken to the operating room (OR) for diagnostic lap and lap appendectomy. Post-op fluids were continued, and the diet was advanced, and was discharged home later that evening. This patient's inpatient admission was warranted based on Milliman Care Guidelines (MCG) abdominal pain, undiagnosed, pediatric ORG: P-05 which states that admission is indicated for abdominal tenderness and evaluation as the patient needed an emergent appendectomy. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for a full hospital admission to is not substantiated.