Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Abdominal Pain.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient presented to the hospital with a history of progressively worsening abdominal pain in the right lower quadrant and a fever of 2-days duration. She has a past medical history of prior episodes of right lower abdominal pain. She was also coronavirus disease (COVID) positive as determined in the emergency department (ED). Her evaluation included physical exam, labs, and a computed tomography (CT) scan. She was without fever at the time of presentation. Her vital signs included a heart rate of 102 beats/minute. She was tender in the right lower quadrant with a positive Rovsing's sign (right lower quadrant (RLQ) pain with palpation of the left lower quadrant (LLQ)). Lab data identified a normal white blood cell count (WBC) of 10.4 thousand (K). A computed tomography (CT) scan identified a thickened appendix that did not fill with contrast consistent with appendicitis. Treatment was initiated with intravenous (IV) fluid, IV antibiotics, and serial abdominal exams. Surgical consultation was obtained. A non-surgical approach was initiated due to the positive COVID result.
The patient was noted to have some improvement with regard to the abdominal pain. Her vital signs remained normal throughout the hospitalization without fever. Her diet was advanced and tolerated. She was discharged home with the recommendation for surgical follow up for interval appendectomy.
At issue is the medical necessity of an inpatient stay.
Acute inpatient admission was not medically necessary for this patient.
This patient presented with abdominal pain. The evaluation with examination, lab data, and a CT scan suggested the diagnosis of appendicitis. She was also COVID positive, but was without symptoms attributable to this diagnosis. The initial treatment included nothing by mouth (NPO) status, IV fluid and antibiotics, and serial abdominal exams. The patient responded favorably and was clinically stable for discharge from the hospital with instructions for outpatient follow up.
The submitted clinical documentation does not support the need for an inpatient admission for this patient. The patient presented with abdominal pain due to appendicitis. A nonsurgical treatment plan was initiated due to COVID positivity. She remained stable and was stable for discharge within 48-hours. A lower level of care would have satisfactorily provided for the care provided and would have been consistent with the accepted standard of medical care.
Generally accepted guidelines for patient admission indicate that in the absence of hemodynamic instability, sepsis or toxicity, significant electrolyte imbalance, bleeding, gastrointestinal (GI) obstruction or surgical complications, monitoring of a patient with abdominal pain can be appropriately accomplished a lower level of care. In this case the patient tolerated oral hydration, diet, and was considered to be stable for discharge from the hospital within 48-hours. Inpatient care was not required or medically necessary in this case per generally accepted medical standards.