Diagnosis: Appendicitis
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld

The patient is an adult female with history of pre-diabetes and hypertension (HTN) who presented to the hospital with acute appendicitis signs and symptoms. The patient was hemodynamically stable and had a white blood cell (WBC) of 15. The patient's computed tomography (CT) scan showed uncomplicated appendicitis. The patient underwent uneventful appendectomy and was discharged.

The proposed treatment was not medically necessary.

After reviewing the medical records, this patient does not meet inpatient criteria per the Milliman Care Guidelines for uncomplicated acute appendicitis. This patient was hemodynamically stable on admission; the only significant laboratory value that was abnormal was a white blood cell (WBC) count of 15, and computed tomography that demonstrated uncomplicated appendicitis. The patient underwent uncomplicated appendectomy. There is no documentation supporting that this patient needed inpatient admission due to sepsis or other medical conditions. Inpatient
admission is not medically necessary.