Diagnosis: Digestive System/Gastrointestinal
Treatment: Inpatient Hospital
The insurer denied: Inpatient stay
The denial is: Upheld in whole

The patient is a female who presented to urgent care with right lower quadrant pain and was urged to go to the emergency department for evaluation. The patient's vital signs were unremarkable. The patient had a white blood cell count of 14.3 with a left shift. The patient had a computed tomography (CT) scan of her abdomen and pelvis which demonstrated acute appendicitis. The patient was hospitalized and underwent uncomplicated laparoscopic appendectomy. On postoperative day #1 the patient was doing well and was discharged home. Pathology demonstrated acute appendicitis. The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld in whole.

No, the inpatient stay was not medically necessary. The patient had acute suppurative appendicitis without perforation but did not have evidence of other complications. The patient did very well after surgery. There is no evidence that additional complex testing or therapy other than the surgery was performed. There is no evidence that a complicating event occurred before, during, or after the procedure that required a higher level of care. There is no documentation that the treating team identified conditions or problems specific to the patient that would have required inpatient care. The patient did not have significant dehydration, hemodynamic instability, severe pain requiring frequent or high doses of narcotics, signs of intestinal obstruction, peritonitis, or bacteremia. The provided documentation does not support the medical necessity for an inpatient stay. The patient could have been managed at a lower level of care status.