Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain, fever, and vomiting.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a male. He presented to the hospital with a one-day history of abdominal pain, fever, and vomiting.

On arrival the patient was febrile, tachycardic (pulse rate of 124 beats per minute), and tachypneic (respiratory rate was 32 breaths per minute). White blood cell count was not elevated but left shift was present (87% neutrophils). Physical examination showed epigastric and suprapubic tenderness. Initial suspected diagnosis was acute gastritis and dehydration. Appendicitis was considered a possibility. Ultrasound showed a 6 mm (millimeter) appendix (normal < [less than] 7 mm [millimeter]) with hyperemia. CT (computed tomography) scan of the abdomen and pelvis showed possible tip appendicitis without findings of abscess. Surgery was consulted. The patient was admitted to acute inpatient level of care.

The patient transferred to the ward. Admission orders included nothing by mouth, intravenous fluids, antiemetic medication and antibiotics. Reasons for admission was sepsis and dehydration secondary to acute appendicitis. The patient underwent laparoscopic appendectomy later that day. Findings were "early acute appendicitis." The procedure skin-to-skin was < [less than] 35 minutes in duration. There was no other pathology identified, and the appendix was not gangrenous or perforated. Postoperative orders included pain medication, discontinuation of antibiotics after one postoperative dose, and antiemetic medication.

Pathology report stated, "vermiform appendix with mucosal neutrophils and scattered intramural neutrophils and eosinophils consistent with early acute appendicitis."

The hospital through its agent states that inpatient admission was medically necessary and reasonable. They note the patient was admitted with sepsis and dehydration secondary to appendicitis. It is stated the decision to admit to the inpatient setting was made by the treating Practitioner who had the ability to assess the patient's clinical status after initial aggressive management and weight a multitude of factors.

No, the Inpatient admission was not medically necessary. The care rendered did not require acute inpatient level of care.
The patient presented to the hospital with a one-day history of abdominal pain, fever, and vomiting. The patient met criteria for systemic inflammatory response syndrome (SIRS) and possibly sepsis based on suspected appendicitis. The patient underwent diagnostic workup including laboratory testing, ultrasound and CT (computed tomography) scan. The findings were equivocal for appendicitis. The patient was suspected of having acute gastritis and dehydration. Appendicitis was considered a possibility based on ultrasound showing a 6 mm appendix with hyperemia and CT (computed tomography) showing "possible tip appendicitis."

In either, case the findings would not be sufficient to account for the appendix as the source of the systemic inflammatory response. Admission orders included nothing by mouth, intravenous fluids, antiemetic medication and antibiotics. It is unclear if the patient was initially planned for appendicitis or whether that was decided later that day. The patient underwent laparoscopic appendectomy later that day. Findings were "early acute appendicitis." The procedure skin-to-skin was < [less than] 35 minutes in duration which is not suggestive of a complicated operation. There was no other pathology identified, and the appendix was not gangrenous or perforated. The patient was kept overnight after the procedure and received one dose of antibiotics. The care the patient would have received at a lower level of care would have been identical to that which he received. The most appropriate level of care for appendectomy for non-perforated acute uncomplicated appendicitis is ambulatory.

Laparoscopic appendectomy for non-perforated appendicitis can safely be performed as outpatient with or without overnight observation. Generally accepted practice guidelines for treatment of acute appendicitis without perforation in the pediatric population is considered outpatient with a short period observation postoperatively in some cases.

Yes, the health plan acted reasonably with sound medical judgment in denial of the acute inpatient level of care. The patient could have been treated at a lower level of care without adversely affecting the quality of care delivered or endangering the patient's health or safety and would not compromise the best interests of this patient.
Appendectomy for uncomplicated appendicitis in children is considered ambulatory in most cases. Indications for inpatient admission would be findings of perforated or in some cases gangrenous appendicitis. Neither condition was believed present preoperatively nor found at surgery.

The hospital through its agent states that inpatient admission was medically necessary and reasonable. They note the patient was admitted with sepsis and dehydration secondary to appendicitis. The patient did meet criteria for systemic inflammatory response syndrome but it could not be reasonably suspected that the minimal findings of the appendix were responsible for the inflammatory response and dehydration (appendicitis with SIRS [systemic inflammatory response syndrome] meets definition of sepsis). It is stated the decision to admit to the inpatient setting was made by the treating Practitioner who had the ability to assess the patient's clinical status after initial aggressive management and weight a multitude of factors. The decision to admit in the evening is usually made by a resident in consultation with the attending and is most often a factor based on order sets in the electronic medical record rather than an actual decision process. None of the interventions rendered required acute inpatient care. A lower level of care would not have jeopardized patient health or safety. The care under observation would have been identical to that which the patient received. A lower level of care than acute inpatient would not have changed the care the patient received and would not adversely affect the health outcome for this child. The anticipated length of stay following appendectomy in a pediatric patient is < [less than] 24 hours. In this case, the patient was in fact discharged within 24 hours of the surgical procedure. Acute inpatient level of care was not the appropriate level of care for this diagnosis, procedure, or this patient's care. Acute inpatient care was in excess of the level of care which was necessary to provide safe postoperative treatment.