Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Appendicitis
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

The patient presented to the emergency department (ED) with a three-day history of colicky abdominal pain and one-day history of vomiting. The pain escalated from 4/10 to 9/10. He had no diarrhea or fevers. Vital signs included a temperature of 37.3 degrees Celsius, heart rate 106, respiratory rate 20, and blood pressure 124/70. The examination was significant for no acute distress, moist mucous membranes, right lower quadrant tenderness without guarding or rebound, and a non-focal neurologic exam. He was treated with Zofran and vomited afterward. Laboratory studies revealed leukocytosis (WBC (white blood cell count) 13.16 thousand [K]), left shift (84.9% neutrophils), mild metabolic acidosis (carbon dioxide (CO2) 21), and elevated C-reactive protein (CRP) (16.5). An abdominal ultrasound was done to evaluate for appendicitis revealing a 9 millimeter (mm) probably calcification in the tip suggestive of acute appendicitis. He was treated with intravenous (IV) fluids and subsequently taken to the operating room (OR) the following day for laparoscopic appendectomy. Postoperative pathology revealed perforated appendicitis. He was treated with antibiotics postoperatively. He had two episodes of fever treated with antipyretics. Repeat lab studies revealed resolution of leukocytosis (WBC 9.09 K) and a significant increase in the CRP (231.0). He was able to advance his diet over the course of his stay, and was afebrile more than 24 hours tolerating a regular diet. He was discharged to complete a 10-day course of antibiotics and follow-up with his pediatrician and general surgeon.

Yes, this was medically necessary. Acute inpatient admission is standard of care for patients with complicated appendicitis.
 
Acute appendicitis is one of the most common sources of acute abdominal pain in children, particularly for those between 4 and 15 years of age. While the classic presentation is that of periumbilical abdominal pain that localizes to the right lower quadrant, with anorexia and fever, there are many exceptions to this presentation. Fever may or may not be present, and pain may not yet be localized early in the course of appendicitis. Physical examination findings typically include signs and symptoms of peritonitis with localization to the right lower quadrant, but this is dependent on the intraabdominal location of the appendix. While most patients have an elevated white blood cell count, a normal value does not rule out appendicitis. Diagnostic studies include an abdominal ultrasound and abdominal computed tomography (CT) scan. The usual findings on CT include an enlarged, edematous appendix, with fat stranding in the right lower quadrant indicative of adjacent inflammation. In the absence of classical findings, with up to 50% of children presenting with an atypical history, the differential diagnosis is quite broad. Management of early acute appendicitis includes IV fluids, antibiotics, and pain medication. Appendectomy typically occurs within the first 12-24 hours after diagnosis. Perforation can occur, and results in a much more complicated course.
In the case of complicated appendicitis, "patients with perforated appendicitis should receive post-operative antibiotics until clinical resolution has occurred ...although the length of antibiotic course for perforated appendicitis is not yet standardized, current findings from multiple systematic reviews recommend continuation of antibiotics until resolution of clinical symptoms. This includes normalization of leukocyte count and differential, full return of gastrointestinal function, resolution of fever, and normalization of physical exam." (3)  There is apparent ongoing debate regarding the optimal timing of surgical intervention for complicated appendicitis. Based on the current literature, acute appendectomy is favored over non-operative management due to the increased failure rate and associated morbidity. (4,5) In addition to duration of antibiotic administration, timing of operative management is according to surgeon preference, taking into consideration patient clinical presentation and disease severity.
This patient presented with progressively worsening abdominal pain that localized to the right lower quadrant. He began spiking fevers after admission. Imaging studies and laboratory findings were consistent with acute appendicitis, so he was taken to the OR for laparoscopic appendectomy, noted on pathology to be a ruptured appendicitis. He was treated with parenteral antibiotics consistent with the current standard of care and discharged once afebrile for more than 24 hours and able to tolerate a regular diet. This admission was most consistent with acute inpatient level of care. Outpatient services would not have been appropriate.