Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld.

The patient is a female with no past medical history (PMHX) who presented to the emergency department (ED) with lower abdominal pain which had been progressively worsening. As per the ED provider note, the patient presented to the ED with abdominal pain for 2 days. The patient said the pain started yesterday and resolved completely. She then woke up in the morning with pain. The patient stated she went to the urgent care and was told to come to the ED. The patient stated she did not take anything for pain and the pain was positional. The patient also complained of nausea and constipation for 1 day. She denied vomiting, fever, or chills. The abdomen was soft with normal bowel sounds. There was abdominal tenderness in the right lower quadrant (RLQ) and suprapubic area. There was no guarding. There was cervical motion tenderness and right and left adnexa tenderness. The assessment was appendicitis vs ovarian torsion/cyst rupture vs endometriosis vs urinary tract infection (UTI) vs pregnancy. The plan was labs, computed tomography (CT) of the abdomen. The pregnancy test was negative, and WBC (white blood cells) was 8.2 the plan was discharge following negative CT for appendicitis. The updated provider notes stated CT shows enlarged retrocecal appendix and there is fluid in the cul de sac concerning for acute appendicitis. General surgery noted that they were not convinced findings are for acute appendicitis and they recommended Obstetrics and Gynecology (OB/GYN) consult despite normal pelvic exam.  OB/GYN noted that bedside ultrasound revealed bilateral ovaries without cyst and Doppler flow present. There was free fluid in the pelvis which could represent a ruptured ovarian cyst but unlikely given CT findings. No acute intervention was recommended at this time. The patient was admitted. Repeat WBC was 7.4. The patient was being treated with Rocephin.

The patient did not require acute inpatient admission as the patient should have been cared for based upon an observation admission. The patient presented to the and was admitted with the vague diagnosis of appendicitis versus PID (pelvic inflammatory disease). In fact, initially the attending surgeon noted that he did not think the patient had appendicitis and it appeared as if the patient could have been discharged. The patient was admitted with a normal WBC and was placed on antibiotics. The patient continued to improve and was discharged later. The care could have been done in an observation status without acute admission. 

According to MCG (Milliman Care Guidelines), Inpatient and Surgical Care 25th Edition Abdominal Pain, Undiagnosed ORG: M-05 (ISC) admission may be indicated for 1 or more of the following: hemodynamic instability, severe pain requiring acute inpatient management; Peritoneal signs; Identification of etiology or finding that requires inpatient care (e.g., aortic dissection, bowel perforation, bowel ischemia, visceral organ torsion; intestinal obstruction; Evaluation requires patient to not eat or drink for extended period (e.g., more than 24 hours); Inability to maintain oral hydration (e.g. needs IV fluid support) that persists after emergency department and observation care treatment; Suspected toxic megacolon; Bacteremia; Procedure that cannot be performed on ambulatory basis; Parenteral nutrition regimen that must be implemented on inpatient basis.  The goal length of stay is ambulatory or 1 day. 

This patient did not have any indication for admission based upon the above criteria. The patient had stable vital signs and did not have criteria from above that would have required inpatient procedure. There was no emergent procedure performed but rather observation was required.  She should have been treated with an observation status and did not require acute inpatient hospitalization for this.

The health care plan did act reasonably and with sound medical judgment.  The health plan acted reasonably with sound medical judgment in the best interest of the patient.

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