Diagnosis: Appendicitis
Treatment: Inpatient admission

The insurer denied the inpatient admission. The denial was upheld.

This is a female patient with a medical history of hypertension, caesarean section, obesity, and tobacco smoker. The patient presented to the emergency department (ED) with complaints of epigastric pain that radiated to the right and left lower quadrants with associated nausea and vomiting. The patient's presenting vital signs were:
blood pressure of 161/88, pulse of 80, and temperature of 97.9. The abdomen was soft and non-distended with normal bowel sounds; tenderness was noted in the epigastric area. There was a negative Murphy's sign. The patient was admitted to the hospital with epigastric pain, appendicitis. An ultrasound of the right upper abdomen was done that revealed cholelithiasis without evidence of cholecystitis, extrahepatic biliary ductal dilatation to 9 mm and hepatic steatosis. A computed tomography (CT) scan of the abdomen and pelvis revealed acute appendicitis, 9 mm appendicolith at the appendiceal base. The patient underwent a laparoscopic appendectomy under general anesthesia. The patient was stabilized and discharged.

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient.

Acute, uncomplicated appendicitis being treated with laparoscopic appendectomy does not mandate inpatient admission. Discharge may be safely undertaken once the operation is completed and the patient's pain is well controlled with a safe discharge plan. The patient went home the following day; the patient should have been admitted to observation. In fact, data has emerged that discharge on the same day of surgery or within 12-24 hours after surgery is safe based on large national database study (Grigorian et al., 2019). Another study found that implementing a protocol to discharge patients within 24 hours of laparoscopic appendectomy resulted in a successful discharge in 95% of patients with an extremely low return to hospital rate (Bradley et al., 2019). Therefore, this patient should not have been admitted to inpatient and could have been successfully managed as an outpatient.

Based on the above, the medical necessity for the inpatient admission is not substantiated. The insurer's denial is upheld.