Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis. 
Treatment: Inpatient Admission. 

The insurer denied the inpatient admission. 
The health plan's determination is upheld. 

The patient is a female with medical history significant for attention deficit hyperactivity disorder (ADHD), anxiety, and depression that presented to the emergency department (ED) with three-hour history of worsening right lower quadrant pain. Her pain was rated 10 out of 10, radiating to the left lower quadrant and right back associated with nausea, worse with movement. The pain was constant and associated with diaphoresis, shortness of breath, and palpitations. Her vital signs included temperature 97.8, heart rate 121, respiratory rate 22, and blood pressure 107/64. The examination was significant for very uncomfortable appearance, in severe pain, moist mucous membranes, clear lungs, focal tenderness at McBurney's point with positive Rovsing sign, guarding with no rebound, holding herself still due to pain with movement, and non-focal neurologic examination. 
The laboratory evaluation was significant for potassium 3.2, white blood cell count (WBC) 17.28 with 83 percent (%) neutrophils and her hemoglobin was 11.2. The urinalysis was significant only for small ketones. The appendix ultrasound revealed free fluid in the right lower quadrant extending to the right adnexa without visualizing the appendix. The pelvic ultrasound revealed small amount of fluid in the cul-de-sac and right adnexal regions with no evidence of ovarian torsion but visualized ovarian cyst measuring 3.2 centimeters (cm). She was treated with intravenous (IV) fluids and Morphine for pain. Surgery was consulted with plans to go to the operating room (OR) for diagnostic laparoscopy due to peritoneal signs. Intra-operatively she was found to have a normal non-torsed right ovary and an inflamed non-perforated non-gangrenous appendix. She underwent complete appendectomy with minimal blood loss. Post-operatively, she reported stabbing pain at the incision site uncontrolled with pain medication. She had not yet passed gas or stool. The repeat laboratory studies included a white blood count (WBC) of 10.11. She was instructed to get out of bed and ambulate as tolerated. She was subsequently deemed stable for discharge the day after surgery to follow-up in two weeks. 

Acute appendicitis is one of the most common sources of acute abdominal pain in children, particularly for those between 4 and 15 years of age. While the classic presentation is that of periumbilical abdominal pain that localizes to the right lower quadrant, with anorexia and fever, there are many exceptions to this presentation. Fever may or may not be present, and pain may not yet be localized early in the course of appendicitis. Physical examination findings typically include signs and symptoms of peritonitis with localization to the right lower quadrant, but this is dependent on the intraabdominal location of the appendix. While most patients have an elevated white blood cell count, a normal value does not rule out appendicitis. Diagnostic studies include abdominal ultrasound and abdominal computed tomography (CT) scan. The usual findings on CT include an enlarged, edematous appendix, with fat stranding in the right lower quadrant indicative of adjacent inflammation. In the absence of classical findings, with up to 50% of children presenting with an atypical history, the differential diagnosis is quite broad. Management of early acute appendicitis includes intravenous (IV) fluids, antibiotics, and pain medication. Appendectomy typically occurs within the first 12-24 hours after diagnosis. Perforation can occur, and results in a much more complicated course. 
While it was not unreasonable for her to remain hospitalized post-operatively to monitor for adequate pain control and adequate intake, she was overall hemodynamically stable with no indication of impending sepsis and no indication of appendiceal rupture.