Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal pain
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is overturned. 

The patient is a female child with unremarkable medical history. She was referred to the ED (emergency department) with abdominal pain, fever, vomiting, and concern for appendicitis.

The patient was found to be tachycardic, with abdominal tenderness. Laboratory evaluation revealed hematuria, leukocytosis, metabolic abnormalities, and elevated inflammatory markers. Ultrasound was unremarkable, but CT (computed tomography) scan revealed mild mural enhancement with adjacent inflammatory fat stranding likely representing tip appendicitis with associated lymphadenopathy in the right lower quadrant and bladder wall thickening. Surgery was consulted with recommendations for parenteral antibiotic therapy (Zosyn) and admission for ongoing care.

Admission orders included nothing by mouth, IV (intravenous) fluids, IV (intravenous) Tylenol for pain, and parenteral antibiotic therapy, with plans to proceed with non-operative management. Stool studies were sent because of diarrhea that started around the time of admission. She was able to advance to regular diet. She was not complaining of pain. She remained afebrile. She was subsequently discharged to home to complete a course of antibiotics with Augmentin and follow-up in the outpatient setting.

Yes, the Inpatient admission was medically necessary.
Acute appendicitis is one of the most common sources of acute abdominal pain in children, particularly for those between four 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 CT (computed tomography) scan. The usual findings on CT (computed tomography) 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 IV (intravenous) fluids, antibiotics, and pain medication. Appendectomy typically occurs within the first 12 to 24 hours after diagnosis. Perforation can occur, and results in a much more complicated course. Tip appendicitis represents inflammatory changes of the distal end of the appendix. Not all patients with tip appendicitis go on to develop full-blown appendicitis. For those patients with otherwise low clinical suspicion of acute appendicitis, conservative management with parenteral antibiotics may be appropriate.

In this patient's case, there was radiographic evidence of tip appendiceal inflammation and laboratory abnormalities to substantiate. The child was also clinically ill, with abdominal pain, vomiting, fever, and dehydration. Acute inpatient admission was medically necessary in this case consistent with the current standard of care to treat conservatively with parenteral antibiotics and monitor for progression of illness with serial examinations. She could not have been safely or appropriately managed at a lower level of care or in the outpatient setting.