Diagnosis: Abdominal pain

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld


The patient presented with abdominal pain that radiated to the right lower quadrant (RLQ). He was afebrile but had hypertension. Localized rebound and guarding were present. The white blood cell (WBC) count was 15.2. The computerized axial tomography (CAT) scan showed a thick-walled hyperemic appendix with mild peri-appendiceal inflammatory changes. Intravenous (IV) antibiotics were given. The leukocytosis resolved and he was discharged on oral antibiotics.

Medical necessity was determined using Milliman Care Guidelines (MCG) guideline MG-GAS for Gastroenterology. Clinical Indications for admission are discussed for nonoperative management of acute appendicitis. These indications include having a complication such as abscess, perforation, or diffuse peritonitis. Uncomplicated appendicitis is also an indication for admission if there is hemodynamic instability, immunodeficiency, active malignancy, acute kidney failure, or failure of observation care with worsening clinical findings. The patient did not have these conditions.

This patient had right lower quadrant (RLQ) abdominal pain with inflammation of the appendix. Intravenous (IV) antibiotics were started, and his symptoms improved. He did not have failure to respond to observation care or develop a complication such as an abscess or perforation. He did not meet Milliman Care guidelines (MCG) criteria under Gastroenterology for inpatient care.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for inpatient admission is not substantiated.