Diagnosis: Abdominal pain
Treatment: Inpatient admission
The health plan denied coverage of the Inpatient admission.
The denial is upheld.

This patient is a previously healthy female who presented to the emergency department (ED) with the complaint of abdominal pain of two-days duration.

The patient's examination revealed right lower abdominal tenderness. Vital signs were normal at the time of presentation. The white blood cell (WBC) count was normal at 8.69 thousand (K). Surgical consultation was obtained. Computed tomography scan was completed showing findings of acute appendicitis. The patient was started on intravenous antibiotics. The patient underwent laparoscopy with appendectomy for the condition of appendicitis. Surgical findings included acute nonperforated appendicitis.

Following surgery the patient was treated with intravenous fluid and analgesia. Vital signs were consistently normal in the perioperative period. She was transitioned to oral medications and diet. She was discharged from the hospital following a period of recovery.

Acute inpatient hospitalization was not medically necessary for this patient. The medical records support that this patient could have been reasonably and safely monitored with an observational status.

This patient presented with abdominal pain. The evaluation with examination, lab data, and computed tomography scan supported the diagnosis of acute appendicitis. The patient underwent uncomplicated appendectomy. She was admitted to an inpatient level of care and was discharged from the hospital on the first post-surgical day.

There is no clinical documentation to support the need for inpatient admission on these dates. The patient remained hemodynamically stable throughout the perioperative period, there was no fever, or documented complication of surgery. This patient's clinical needs could have been satisfied with an observational level of care. This lower level of care would have provided for pre-surgical assessment, surgical treatment and post-surgical recovery including overnight observation (if required).