Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute appendicitis
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission 
The denial is overturned

The patient is a teen male with a past medical history of non-operative management of acute pancreatitis and severe acute respiratory syndrome (SARS) Coronavirus disease (COVID) infection one week ago that presented to the hospital for assessment of abdominal pain starting in the last 24 hours. Patient noted periumbilical discomfort that later radiated to the right lower quadrant associated with decreased appetite and loose stool. The patient's initial vitals were notable for heart rate (HR) 123, temperature 98.9 Fahrenheit, blood pressure (BP) 111/73, respiratory rate (RR) 20 and room air oxygen saturation of 99%. Admitting laboratories were notable for sodium 138, potassium 4.2, bicarbonate 28, blood urea nitrogen (BUN) 11, creatinine 0.6, glucose 82, white blood cell (WBC) 9.5 with a left shift (neutrophils 71%[percent], no bands), hemoglobin 14, platelets 282, albumin 4.7, aspartate aminotransferase (AST) 19, alanine transaminase (ALT) 12, Bilirubin 1.2/0.2, Alkaline phosphatase 182 and lipase 33. A respiratory pathogen panel was positive for SARS-COVID. Urinalysis was notable for specific gravity 1.019, pH 6.5 and dip positive for trace ketones and leukocyte esterase. Physical exam showed an awake and alert teen in mild discomfort. There was 3/10 tenderness to palpation in the right lower quadrant (RLQ). An abdominal sonogram showed a 7 millimeter (mm) non-compressible tubular structure with surrounding bowel wall edema consistent with acute appendicitis. Given his Covid infection with residual cough he was admitted for non-operative management. He received a 770 cubic centimeter (cc) normal saline bolus followed by dextrose 50% (D5) normal saline at 80cc/hour. In addition, he received Cefoxitin and Toradol intravenously and was made nothing by mouth (NPO) status. His admitting weight was 38.7 kilograms, and his height was 159.7 centimeters (cm). His pain improved and he remained afebrile and hemodynamically stable. His diet was resumed, and he was transitioned to oral Augmentin. He continued to tolerate a diet without vomiting or pain and was discharged the following day for outpatient follow-up. 
 
This teen appears to have recurrent early acute pancreatitis with residual symptomatic SAR COVID infection. The updated recommendations for management of early acute appendicitis summarized in a review from UptoDate was reviewed. 

Early appendicitis is defined as appendicitis without evidence of perforation.
Appendectomy - For children with early appendicitis who have risk factors for perforation, we recommend appendectomy. Risk factors for perforation include any one of the following:
Abdominal pain for >(greater then)=(equal) 48 hours
WBC count >18,000
Elevated C-reactive protein
Appendicolith present on imaging
Appendix diameter >1.1 cm on imaging
Preoperative concern for rupture based upon clinical findings

Since the risk of progression to either abscess or perforation is significant then trying to do this in any setting other than the inpatient setting would be consider dangerous and ill-advised. Regarding the acute inpatient admission, the determination by the carrier that the admission was not medically necessary was not correctly applied, objective, clinical valid, compatible with established principles of health care and flexible enough to permit justified variation. This decision was rendered based on review of the hospital record and the reviews from UptoDate summarizing the management of acute pancreatitis on children and the algorithm for the approach cited above.

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

The insurer's denial of coverage for the acute inpatient services is overturned. Medical necessity is substantiated.