Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal-Appendicitis
Treatment: Inpatient hospital stay
The health plan denied the inpatient stay as not medically necessary. 
The reviewer has overturned the health plan determination in whole.

The patient presented to the emergency department (ED) with a history of progressively worsening abdominal pain over a period of 2-weeks. Comorbid health conditions included gastroesophageal reflux disease (GERD), migraines and peptic ulcer disease. Evaluation included physical exam, labs, and computed tomography scan. The patient was without fever at the time of presentation though the heart rate was 115/minute. Lab data identified a white blood cell count (WBC) count of 15 K. blood urea nitrogen (BUN) and Creatinine were normal at 10 and 0.64. The computed tomography (CT) scan supported the diagnosis of acute appendicitis. There was peri appendiceal inflammatory change without mention of abscess. Treatment was initiated with intravenous (IV) fluid and antibiotics. Surgical consultation was obtained on the day of presentation.
The patient was admitted to the hospital. She was taken to surgery for planned laparoscopic appendectomy. This procedure was limited to diagnostic laparoscopy due to intra-operative findings of a markedly inflamed appendix with thickening extending into the cecum, but no perforation or necrosis. The patient was treated with IV antibiotics (Levaquin and Flagyl). She did require additional fluid bolus overnight due to a low urine output. She was NPO until the day before discharge.

The inpatient hospital stay was medically necessary for this patient. This patient presented with abdominal pain. Evaluation with examination, lab data, and CT scan confirmed the diagnosis of appendicitis. The initial treatment appropriately included nothing by mouth status, IV fluid, and IV antibiotics. The patient was taken for laparoscopic appendectomy. Due to intra-operative findings of significant peri appendiceal inflammation, it was decided to not undertake an extensive surgical dissection and pursue a non-operative treatment approach with NPO status, IV fluid and IV antibiotics. The patient required urgent surgical evaluation, follow up lab data, provision of IV antibiotics, and IV fluid during the period of NPO status. It was anticipated that this treatment would span a period of greater than 48-hours. Inpatient care is indicated in the setting of peritoneal signs or other signs or symptoms of acute abdominal disease. In this case, the patient had significant right lower abdominal pain and tenderness at the time of presentation and was found to have an intra-abdominal infection due to appendicitis. Inpatient care was medically necessary for this patient on the specified dates in order to provide the prescribed therapy with parenteral medication and close follow up given the possibility of clinical deterioration. The nonsurgical treatment for the diagnosis of appendicitis was most appropriately provided with an inpatient level of care. An inpatient level of care was appropriate, medically necessary and supported by the medical records and medical standards in this case.