Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Right lower quadrant tenderness

Treatment:  Inpatient admission

The insurer denied coverage for inpatient admission. The denial was upheld.

This patient is a male child who presented to the Emergency Room when he complained of fever as high as 103 degrees Fahrenheit, abdominal tenderness, headaches, dizziness, and nasal congestion.  The patient had been to the Emergency Room three times with this symptomatology and had had a computed tomography (CT) scan that suggested early appendicitis.  Surgery was then consulted.  The right lower quadrant was tender to palpation.  Intravenous (IV) fluids were administered.  It was felt by surgery that his history was inconsistent with appendicitis.  He was admitted to the hospital, and the next day he was hungry, pain free, had breakfast, and was discharged to out-patient care. 

The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient.  The treatment of acute appendicitis is considered ambulatory evaluation and treatment. 

This patient had a temperature that ranged from 98.9 to 100.4 degrees Fahrenheit.  Surgery felt that this was a viral illness and discontinued the antibiotics.  There was a soft abdomen with a suggestion of rebound in the right lower quadrant.  The CT was not impressive, and the picture was consistent with a viral illness (such as mesenteric adenitis).      

The inpatient admission is not considered medically necessary for this patient. 
The medical records provided do not establish medical necessity for a full acute care facility admission.  The patient's clinical history was not consistent with appendicitis.  The pediatric radiology team did not believe the CT scan was convincing of appendicitis.  The ED Pediatric note states the patient was not in any pain, noted with pink eye (conjunctivitis) for two days, fever for 7 days and no difficulty breathing. 

Per the history and physical, this was the patient's third visit to the Emergency Department in a matter of days.  He had been diagnosed with allergic reaction on the first visit and viral illness on a subsequent visit.  Of note, the patient's lab reports has adenovirus antigen detected.  The Centers for Disease Control (CDC) in part states, "Health professionals should consider adenoviruses as possible causes of upper respiratory infection, lower respiratory infection such as pneumonia, and conjunctivitis (individual cases or outbreaks)."  Regarding treatment of adenovirus the CDC states, "There is no specific treatment for people with adenovirus infection.  Most adenovirus infections are mild and may require only care to help relieve symptoms, such as over-the-counter pain medicines or fever reducers."

Per Dahabreh,  IJ., et al, (2015), "Clinical symptoms and signs, along with the results of laboratory or imaging tests, can be combined into multivariable diagnostic scores (sometimes referred to as "clinical prediction rules"), multivariable that synthesize the findings of different investigations to determine the most likely diagnosis...."  

Neither the Pediatric Appendicitis Score nor Alvarado score was noted in the medical records.  The patient was stable hemodynamically and was negative for urinary tract infection.  There were no signs of impending sepsis or of frank sepsis.  Medical necessity for hospital admission has not been established.  

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