Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal 
Treatment: Inpatient Hospital 
The insurer denied the inpatient stay. 
The denial is upheld.

The patient is a male with unremarkable past medical history who presented to the emergency department with right lower quadrant abdominal pain that started one day before the presentation. The patient described the pain as sharp. It was associated with nausea and vomiting. The patient denied any previous similar episodes. The patient denied diarrhea, fever, chest pain, cough, or shortness of breath.

At the time of the initial evaluation, he was afebrile. The respiratory rate was 16 breaths/min, blood pressure was 117/55, oxygen saturation was 98% on room air.

The patient was in no acute distress. The head, eyes, ears, nose, throat (HEENT) exam was within normal limits. There was regular rate and rhythm, without murmurs, rubs, or gallops. Lungs were clear to auscultation without wheezes, rales, or rhonchi. The abdomen was soft, tender to palpation in the right lower quadrant with rebound tenderness. The rest of the physical exam was unremarkable.

Laboratory evaluation revealed that white blood cell count was 14.06, hemoglobin was 15.2, hematocrit was 44.5, and platelets were 201. Sodium was 139, potassium was 4.1, chloride was 108, bicarbonate was 26, blood urea nitrogen (BUN) was 16, creatinine was 1.06, and glucose was 144. Liver function tests were within normal limits. Urinalysis was unremarkable.

Computed tomography (CT) scan of the abdomen and pelvis revealed findings most consistent with early acute appendicitis.

The patient was admitted to the hospital with acute appendicitis and leukocytosis.

In the hospital, the patient was evaluated by the general surgery service who suggested that he had acute appendicitis and recommended laparoscopic appendectomy.

The appendectomy was performed. In the postoperative period, the patient developed urinary retention that resolved quickly and was started on Flomax.

Overall, this patient remained in stable clinical condition and was discharged from the hospital.

The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld in whole.

Based on the current standards of care, the admission for treatment of acute uncomplicated appendicitis, including surgical intervention, is usually conducted at a lower level of care status.

In this clinical case, the patient remained afebrile and hemodynamically stable during the entire hospitalization. The patient underwent an uncomplicated laparoscopic appendectomy.

Following the appendectomy, the patient tolerated his diet.

The review of the medical records demonstrated no significant laboratory abnormalities that would necessitate the care at the acute inpatient level. The urinary retention after the surgery was short-lived and did not necessitate any interventions requiring admission at the acute inpatient level of care.

The review of the medical records did not demonstrate any circumstances that would justify the acute inpatient level of care in this clinical case. The patient could have been managed at a lower level of care status.