This is a case of a patient with no significant past medical history, who presented to the emergency department with abdominal pain. The patient was also approximately 6 weeks pregnant, with some vaginal spotting. Workup in the emergency room revealed an intrauterine pregnancy and the OB/Gyn service ruled out an ectopic pregnancy. The acute care surgery service was consulted to rule out appendicitis. A right lower quadrant ultrasound did not visualize the appendix. After examination and assessment of the clinical picture, the acute care surgery service had low suspicion for acute appendicitis. The patient was admitted to the acute care surgery service.

The health plan's determination is upheld. The inpatient stay was not medically necessary. The patient's treating team felt that the duration of stay was likely less than a 2 day stay. It is important to recognize that appendicitis in pregnancy has been proven to result in multiple detrimental pregnancy outcomes. Furthermore, diagnosing appendicitis in pregnancy is particularly challenging, as the gravid uterus displaces the appendix and other viscera. Additionally, lab tests are often abnormal in pregnancy and thus often are not helpful in the diagnosis of appendicitis in the pregnant woman. Imaging of the appendix in pregnancy is controversial. Ultrasound is used as a first test, as it is quick and requires no radiation or contrast exposure. However, in the case of this patient, the appendix was not visualized. Had the surgery team had more suspicion of appendicitis, a magnetic resonance imaging (MRI) or possibly even a computed tomography (CT) scan would have been obtained. However, the suspicion was very low. The plan for pain control, intravenous (IV) fluids, and serial exams was appropriate. There are no pain medications ordered in the chart, nor is there any charting that the patient received any while inpatient. Such a plan did not require an acute admission. The fact that the patient was pregnant did not influence the care, as the fetus was previable and also had no heartbeat to monitor, even if monitoring was desired, although not indicated. The patient was hemodynamically stable and had no concerning signs that she needed an inpatient level of care. The patient did not require an inpatient admission.