Diagnosis: Acute appendicitis
Treatment: Full hospital admission
The insurer denied coverage for full hospital admission.
The denial is overturned.

According to the medical records, this is a child who was brought into the Emergency Room (ER) with a 2-day history of sleeplessness due to abdominal pain, nausea and vomiting, and a temperature at home of 103 degrees F (Fahrenheit). A computerized tomography (CT) scan showed a fluid filled enhanced wall thickened appendix. White blood cells (WBC) were 19.3. There apparently were no incidences or complications intraoperatively or postoperatively. The appendix was retrocecal and suppurative but not ruptured. He did well and was discharged to office visit follow up. The full admission was denied on the basis of lack of acuity. This admission was justified as the patient, with a leukocytosis and left shift as is demonstrated here, is on the verge of becoming septic with a not yet ruptured appendix.

"Treatment / Management in the emergency department, the patient must be kept nil per mouth (NPO) and hydrated intravenously with crystalloid, and antibiotics should be administered intravenously as per the surgeon. The responsibility for the consent falls on the surgeon. The gold-standard treatment for acute appendicitis is to perform an appendectomy. Laparoscopic appendectomy is preferred over the open approach. Most uncomplicated appendectomies are performed laparoscopically. Several studies have compared the outcomes with the laparoscopic appendectomy group and patients who underwent open appendectomy." (Jones, MW. et al. 2021)

"Acute appendicitis (AA) develops in a progressive and irreversible manner, even if the clinical course of AA can be temporarily modified by intentional medications. Reliable and real-time diagnosis of AA can be made based on findings of the white blood cell count and enhanced computed tomography. Emergent laparoscopic appendectomy (LA) is considered as the first therapeutic choice for AA. Interval/delayed appendectomy at 6-12 week after disease onset is considered as unsafe with a high recurrent rate during the waiting time. However, this technique may have some advantages for avoiding unnecessary extended resection in patients with an appendiceal mass. Non-operative management of AA may be tolerated only in children. Postoperative complications increase according to the patient's factors, and temporal avoidance of emergent general anesthesia may be beneficial for high-risk patients." (Hori, T. et al. 2017)

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for full hospital admission is overturned. Medical Necessity is substantiated.