Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Appendicitis
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is overturned. 

This is a male patient with a past medical history notable for an adenoidectomy that was referred to the Emergency Department (ED) for evaluation of 2-3 days of constant abdominal pain in the periumbilical region with referral to the right lower quadrant, nausea without vomiting, watery non-bloody diarrhea and subjective fever. The patient noted that his pain was actually improving by the time of presentation but made worse with moving about. The patient was able to tolerate oral intake. The patient's abdomen exam was notable for normal bowel sounds, soft with mild tenderness to palpation in the right lower abdominal quadrant and epigastric region. There was no distension, rebound, guarding, masses, or organomegaly noted. The patient was evaluated by pediatric surgery and was admitted with a diagnosis of possible appendicitis, gastroenteritis or early inflammatory bowel disease.  The patient was discharged after treatment and once medically stable. 

Based on the review of the medical record, this patient appeared to have acute onset mild/moderate, abdominal discomfort with associated nausea without vomiting or significant dehydration and non-bloody diarrhea consistent with gastroenteritis or appendicitis. The patient was able to tolerate a diet prior to admission and never vomited once permitted to resume his diet after an uneventful period of observation. Both the patient's sonogram and computed tomography (CT) scan failed to identify a dilated, obstructed appendix and was most consistent with bowel inflammation. According to UpToDate review of the "causes of acute abdominal pain in children and adolescents", the reasons to admit such a patient would include signs of significant dehydration poorly responsive to intravenous (IV) hydration in the ED, hemodynamic instability, significant electrolyte imbalance, demonstrated oral hydration intolerance to oral challenge, poorly controlled pain with an oral pain medication regimen, concerning physical exam findings for a surgical process (bowel strangulation, appendicitis) or findings consistent with significant blood loss or bowel obstruction.  In this case, there appears to be adequate suspicion for appendicitis as stated in the hospital record to justify for this patient's acute inpatient admission.

According to an UpToDate review of "Acute appendicitis in children: Clinical manifestations and diagnosis", the Pediatric Appendicitis Score (PAS) is a tool that utilizes history, physical examination, and laboratory results to categorize the risk of appendicitis in children with abdominal pain on a 10 point scale. In several prospective observational studies, the mean PAS was significantly higher in children with appendicitis than in children without appendicitis. In this case, while the patient's sonogram and computed tomography (CT) scan failed to demonstrate appendicitis definitely in this patient, the patient's PAS was 7 placing him at significant risk of appendicitis. The patient's preserved appetite, borderline leukocyte count and CT scan findings suggesting an alternative diagnosis make appendicitis less likely but did not exclude this possibility, and thus, meeting criteria for medically necessity for hospital admission for observation and serial exams. The patient's gradual improvement while admitted eventually led surgery to conclude that no operative intervention was necessary and he was discharged.  The fact that surgery never occurred is not sufficient to downgrade this patient's status to observational care only.  

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the inpatient hospital admission should be overturned. The medical necessity is substantiated.