Diagnosis: Abdominal Pain (status-post surgery)
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is upheld.

The patient is an adult female. She presented to the hospital with right lower quadrant pain. A computed tomography (CT) scan showed uncomplicated appendicitis. Her white blood cell count
(WBC) was 12. She was afebrile. Appendectomy was performed, and she was discharged.

The inpatient admission was not medically necessary.

The patient's clinical situation did not meet medical necessity requirements for inpatient admission for diagnosis of acute appendicitis. This patient underwent an uncomplicated appendectomy and was discharged. There was no documentation that supported inpatient admission for the above diagnosis. MCG (Milliman Care) guidelines suggest that this procedure is ambulatory in nature, and there is no documentation that supports necessity for inpatient admission. Therefore, the inpatient admission was not medically necessary.