Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal/Abdominal Pain/Stomach Pain
Treatment: Inpatient Hospital
The health plan denied the requested inpatient stay as not medically necessary. 
The health plan's determination is overturned.

The patient is a girl who presented with abdominal pain and vomiting. The patient was well until the month prior to presentation when she developed acute appendicitis with perforation and had a complicated course with abscess formation after surgery and a prolonged hospitalization. She required a Jackson-Pratt (JP) drain and 21 days of antibiotics. Following discharge, she was doing well at home until she developed abdominal pain and nausea the evening of her presentation. She vomited 3 times at home and was subsequently brought to the emergency department for evaluation.
In the emergency department, she was described as being uncomfortable and pale. She was lying on a stretcher and describing 9 out of 10 pain, and she vomited several times in triage. She initially had abdominal tenderness on exam. A computed tomography (CT) scan of the abdomen was performed which showed a possible small bowel stricture. She was given Zofran as well as a normal saline bolus. Surgery was consulted and recommended admission for serial abdominal examinations and monitoring.
Following the hospital admission her pain improved, and after a bowel movement the next morning, was able to tolerate an oral challenge without difficulty. She was felt to be stable for discharge to home with stool softeners and with follow up as an outpatient.
The admission is under review for the medical necessity of the inpatient stay.

I overturn, in whole, the health plan's determination of medical necessity.

Yes, the requested health service/treatment of an inpatient stay was medically necessary for this patient.
This is a young girl who presented with severe abdominal pain and vomiting after a very complicated course of acute appendicitis with abscess. At the time of her presentation in the emergency department she was doubled over with 9 out of 10 pain, and she vomited several times. Her abdominal CT scan was concerning for a possible stricture. Therefore, she required hospital admission for ongoing evaluation and additional prompt treatments as needed.
According to the Milliman Care Guidelines (MCG) Health Inpatient and Surgical Care Guidelines, 25th edition, Abdominal Pain, Pediatric, a hospital admission is indicated for patients with severe pain requiring inpatient management and with intestinal obstruction. This patient had severe pain and there was concern for stricture causing obstruction in the setting of a known recent complicated course of acute appendicitis, which increases the risk for later complications.
Up to 55 percent of children with advanced appendicitis have a complication, such as infection, bowel obstruction, or unplanned hospital admission. Signs of obstruction are clinical features associated with serious intra-abdominal conditions that require prompt diagnosis and treatment. Hospital admission for observation and serial examinations should occur for any patient with signs of obstruction for whom a cause cannot be identified.
This patient had signs of obstruction after a known complicated course of appendicitis, and therefore required a hospital admission for care.