Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis.

Treatment: Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission.

The denial is upheld. 

This patient is a male child with a past medical history notable for mild asthma. The patient presented to the Emergency Department (ED) for assessment and management of acute appendicitis. The patient presented with 1 week of abdominal discomfort associated with 3 days of loose stool and non-bilious, non-bloody vomiting x 2 episodes. There were no associated fevers, weight loss, travel or sick contacts. His vitals were notable for Blood Pressure 111/69, Heart Rate 87, Respiratory Rate 24, Temperature 36 Celsius and room air oxygen saturation 98%. His admitting weight was 43.8 kilograms. His physical exam was notable for a well-developed, well- nourished boy in no apparent distress. He had moist mucus membranes and normal capillary refill. He had rhonchi noted on lung exam. His abdomen was flat with tenderness to palpation in the right upper and lower quadrants with a positive obturator sign. There were no masses, organomegaly, rebound or guarding. Admitting labs showed sodium 137, potassium 4.7, bicarbonate 26, blood urea nitrogen (BUN) 14, creatinine 0.53, white blood count (WBC) 16.6 with a left shift (89.7% neutrophils), hemoglobin 14.1, platelets 355, lipase 5, international normalized ratio (INR) 1, and a normal liver profile. A urinalysis showed specific gravity 1.025, potential of hydrogen (pH) 6, and dip positive for protein. 

A limited abdominal sonogram showed a non-compressible appendix with trace peri-appendiceal fluid. Intravenous (IV) fluids with 5% dextrose in normal saline (D5NS) were started at 85 cubic centimeters (cc)/ hour and IV ceftriaxone and Flagyl were administered. The patient was taken to the operating room for a laparoscopy appendectomy. Intra-operative findings showed an adherent inflamed appendix with some peri-appendiceal fluid. Pathology showed an acutely inflamed appendix with peri-appendiceal inflammation. No drains were left in place. The patient was treated as having perforated appendicitis and was admitted post-operatively for 24 hours more of IV antibiotics. He tolerated some fruit on post-op day # 0 and breakfast (fruit, eggs, waffles) on post-op day # 1. IV fluids were stopped, antibiotics were changed to oral Augmentin and pain medications were transitioned to oral agents. No repeat laboratories were performed. He remained afebrile since presentation. He continued to tolerate his diet.
  
This patient appeared to have appendicitis with peri-appendiceal inflammation and possible perforation. There seems to be some conflicting information from the operative findings, the patient's clinical course and the pathology findings. Certainly, there was some local peritoneal inflammation and fluid in the right lower quadrant, but this alone does not equal a perforation. This patient may or may not have had a true appendiceal perforation. Regardless of the presence of perforation or not, his clinical presentation was that of a standard risk appendicitis with good prognosis. This patient could have been observed overnight with discharge the following day. Given his intra-operative findings, performing this procedure as an ambulatory case seems inappropriate and a short period of observation seems prudent to ensure that his course would remain favorable. This could have occurred at the observational level of care. 

The inpatient acute care setting was not medically necessary or in the best interest of the patient. The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the inpatient hospital admission is upheld. Medical necessity is not substantiated.