Diagnosis: Appendicitis
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld.

The patient is a female. She was admitted for acute appendicitis. Her medical history was significant for hypercholesterolemia, diabetes, and hypertension. The patient was seen in the ED (emergency department) for two days of dull abdominal pain that progressed. Documentation showed that she had TTP (tender to palpitation) in the RLQ (right lower quadrant), WBC (white blood count) 11, and CT (computed tomography) scan findings of acute appendicitis without evidence of perforation.

The health plan denied coverage of the inpatient admission due to patient not meeting criteria for inpatient admission. This denial was appealed.

No, the Inpatient admission was not medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
The patient was seen in the ED (emergency department), and found to have acute appendicitis. She was evaluated by cardiology and medicine regarding her HTN (hypertension) and diabetes. She was medically optimized. The operative report did not demonstrate any evidence of abscess, perforation , or inflammation that hindered removal of the appendix. The patient was discharged with no documentation regarding pain, diet, and plan for discharge.

The patient could have had a lower level of care (i.e., observation status) rather than inpatient stay. Although the patient has medical co-morbidities, there was no documentation regarding the need for inpatient admission for her acute appendicitis. Health plan acted appropriately to deny the inpatient admission given lack of medical necessity.