Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient admission
The insurer denied the inpatient admission. 
The denial is upheld. 

The patient is a female. She presented with complaint of abdominal pain and vomiting which began on the morning of presentation. The patient was initially seen in Urgent Care and referred to the emergency department due to concerns for appendicitis.

The patient's vital signs on presentation were within normal limits. White blood cell count was mildly elevated to 14,740 with left shift (84% polymorphonuclear leukocytes). Urinalysis was not a clean specimen. Surgery was consulted and recommended evaluation for appendicitis. The patient underwent CT (computed tomography) of the abdomen and pelvis which was inconclusive (the appendix was not clearly identified) and appendicitis could not be ruled out on this exam.

The patient received fluids, anti-nausea medication, pain medication, and antibiotics in the Emergency Department. The patient was admitted to acute inpatient level of care for diagnosis of unspecified appendicitis. Intravenous antibiotics and intravenous fluids were continued.

Surgery saw the patient and the patient continued to complain of pain. The patient had slept comfortably overnight. The plan was to continue antibiotics and intravenous fluids. Diagnostic laparoscopy was to be considered if white blood cell count was increasing. White blood cell count decreased to 8770. The patient was ordered for clear liquids and advanced to full liquids. The plan was to perform serial abdominal examinations.

The patient complained of pain on palpation of the abdomen. She tolerated regular diet. Ultrasound was ordered which showed a small amount of free fluid and an intrauterine contraceptive device. Appendicitis continued to be suspected, which was responding to antibiotics.

The patient's symptoms improved over the next day, leading to the patient's discharge with oral antibiotics.

The acute inpatient was denied as not being medically necessary.

The hospital has appealed the denial of the acute inpatient admission. The appealing hospital through its agent states that the patient was in acute distress on arrival with normal vital signs. The patient received intravenous fluids, medication for pain and nausea, and antibiotics. Labs were normal except mild elevation of white blood cell count. The patient received intravenous antibiotics while admitted and "CBC [complete blood count] monitoring." Surgery determined that the patient did not have appendicitis and she was discharged home. The appeal provides no information as to why the patient could not have received treatment at a lower level of care.

No, the Inpatient admission was not medically necessary.

The patient is a female that presented with complaints of severe abdominal pain and vomiting. White blood cell count was elevated to 14,700 with left shift. COVID (coronavirus disease) testing was negative. Urinalysis showed that it was not a clean specimen and urinary tract infection was not suspected. CT (computed tomography) done did not identify the appendix. CT (computed tomography) is 97% sensitive in picking up appendicitis and the failure to identify the appendix or any secondary signs of appendicitis (example: inflammatory changes or an appendicolith in the area of the cecum) should have ruled out appendicitis. Nevertheless, Surgery opined that appendicitis was still suspected and admitted the patient and started antibiotics. The plan the following day was to consider diagnostic laparoscopy if the white blood cell count increased. The white blood cell count in fact returned to normal, and diagnostic laparoscopy was no longer considered as an option.

Even if the patient had uncomplicated appendicitis and treatment was considered with antibiotics, standard protocols transition the patient to oral antibiotics in 24 hours and discharge the patient. The care rendered did not require acute inpatient level of care, and the four-day hospitalization was not indicated. The patient had normal vital signs, no fever and normalizing white blood cell count by the following morning. Persistent abdominal pain without findings on CT (computed tomography) or ultrasound did not require acute inpatient level of care. The patient could have been cared for at a lower level of care.