Diagnosis: Appendicitis.
Treatment: Inpatient admission.

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

This is a female patient with a history of asthma and low back surgeries. She presented to the emergency department with complaints of abdominal pain. She was referred from urgent care to evaluate for appendicitis. The physical examination revealed she was in no apparent distress. The patient had diffuse tenderness to the abdomen. She refused a pelvic examination and it was recommended she undergo laboratory and diagnostic studies. The laboratory studies revealed she was hemodynamically stable. A computed tomography scan of the abdomen was performed that revealed a 7 mm tip of appendix. The patient was admitted for further observation. The patient was treated with intravenous medications and she was maintained nothing by mouth. The patient was discharged the following day with instruction to follow up.

The patient presented with acute abdominal pain and imaging showed a possibility of early acute appendicitis. No perforation or complications were noted. No clinical instability was documented. The patient did not have any significant co-morbidities placing her at a high-risk needing care at a higher level. In this setting, the appropriate course of action would be to admit under observation and decide on the course of action based on her clinical condition over the 24 hours of observation. Inpatient admission was not necessary based on the information documented.

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

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