Diagnosis: Appendicitis
Treatment: Inpatient admission
The health plan denied: Inpatient admission
The determination is: Upheld

The patient is a female who presented to the emergency department with abdominal pain. She was found to be tender in the right lower quadrant. She had an elevated white blood cell (WBC) count to 14.9. She underwent a computed tomography (CT) scan which showed acute appendicitis, with possible small perforation at the tip. She also had nonspecific gall bladder wall edema. The patient was admitted and received intravenous (IV) antibiotics and fluids. She was evaluated by surgery. The patient underwent a laparoscopic appendectomy. She recovered well and was discharged with follow up with the surgical team.
At issue is the medical necessity of the inpatient admission.
The health plan's determination of medical necessity is upheld in whole.
The requested health service/treatment of inpatient admission was not medically necessary for this patient. Based on all information submitted, the patient did not warrant inpatient admission, and an alternate level of care would have been appropriate. A study from 2016 found that an overwhelming majority of patients diagnosed with acute appendicitis are treated operatively, necessitating admission to the hospital for at least a short time. Timing of appendectomy has also been studied extensively, with no increase in complications if a delay of 12-24 hours if the patient was admitted to the hospital during that time. This patient was not on any blood thinners, which can lead to an increase in bleeding risk. The literature has time and again shown that acute appendicitis without perforation is not an emergency, even though surgical dictum once called it as such. There is a small minority of appendicitis patients that present with severe systemic illness, and from the documented vital signs as well as laboratory studies and exam findings, she did not have severe disease. Before, during, and after the case, the patient remained hemodynamically stable per documentation. There was no care provided that was above and beyond the standard, and therefore, the inpatient admission was not medically necessary.