Diagnosis: Right-lower-quadrant abdominal pain
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a man. His medical history included hypertension. His surgical history was negative. He presented to an emergency department with a one-day history of right-lower-quadrant abdominal pain, loss-of-appetite, nausea, and diarrhea. His vitals were as follows: temperature 98.6, pulse 67, blood pressure 146/62, respirations 16, oxygenation 97%. Serum laboratories demonstrated leukocytosis to 14.53. Computed tomography was negative.

The patient was admitted at an acute inpatient level of care with a diagnosis of acute appendicitis. He was made nil per os [NPO]; provided with intravenous fluids, antibiotics, analgesics, and anti-emetics. The patient underwent laparoscopic appendectomy. Surgery confirmed "acute purulent appendicitis." The procedure and recovery were uncomplicated.

Having returned to his baseline health and function, the patient was discharged home in good and stable condition with outpatient surgical follow-up and prescriptions for anti-hypertensives and analgesics.

No, the Inpatient admission was not medically necessary.

According to several studies, the majority of patients with uncomplicated appendicitis who undergo laparoscopic appendectomy can be treated effectively and safely on outpatient or observational status [Gilliam et al; Cross et al; Cosse et all. In fact, most patients can be discharged from the post-anesthesia care unit -- the recovery room --, precluding the need for inpatient admission, even on observational status [Mitchell et al; Dubois et al; Cash et all. Therefore, for this patient, there was no need for admission at an acute inpatient level of care; this patient could have been treated at a lower level of care.

According to peer-reviewed medical literature, patients with uncomplicated appendicitis who undergo laparoscopic appendectomy can be treated effectively and safely on outpatient or observational status; most patients can be discharged from the recovery room. Therefore, this patient could have been treated at a lower level of care.