Appeal type: Medical necessity
Decision: Upheld

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

The patient is a female. She was seen initially at an outside hospital with a one-day history of abdominal pain and vomiting. Laboratory studies and CT (computed tomography) scan done showed an elevated white blood cell count of 14,500. CT (computed tomography) scan showed appendicitis without findings suggestive of perforation or abscess.  The patient was then transferred to the treating hospital for pediatric specialty care with diagnosis of acute appendicitis. The patient was administered antibiotics prior to transfer.

The patient's vital signs were normal on presentation. The patient was evaluated by pediatric surgery in the Emergency Department and scheduled for laparoscopic appendectomy that day. The patient was admitted to acute inpatient level of care prior to the procedure. (Bed request and second order for inpatient entered).

The patient underwent laparoscopic appendectomy. It was straightforward and less than 45 minutes in duration skin-to-skin. The findings were acute appendicitis without evidence of perforation, gangrene or abscess. The patient was discharged within hours after the procedure that afternoon. Discharge order was entered.

The acute inpatient admission was denied coverage by the health plan as not medically necessary on the basis that the care could have been rendered as observation. This review is for the appeal of the denial of the acute inpatient admission.

The hospital's appeal of denial of inpatient admission by its agent is based on the premise that inpatient admission was medically necessary and that the patient could not have been managed at a lower level of care. The appeal notes, "the patient required inpatient admission for emergent surgery the patient's admission was medically necessary and in accord with the standard of care for acute appendicitis requiring preoperative stabilization, intravenous hydration, and intravenous antibiotics." The appeal letter cites the MCG (Milliman Care Guidelines) guideline for Pediatric General Admission criteria citing "emergency inpatient surgery," and Ambulatory Surgery exception for preoperative situation, condition or finding that warrants inpatient stay as indicated by 1) inpatient care needed for preoperative disease or condition (cited conditions are diagnostic assessment, preoperative hydration, pain control, and intravenous antibiotics) and 2) emergent surgery.

No, the Inpatient admission was not medically necessary. The care rendered did not require acute inpatient level of care.
The patient is a female that presented to the treating hospital. The patient had been evaluated at another hospital and had been diagnosed with appendicitis on CT (computed tomography) scan. The patient was made NPO (nothing by mouth), administered antibiotics, and intravenous fluids and scheduled for laparoscopic appendectomy. The patient was admitted to acute inpatient level of care prior to the surgical procedure. The patient underwent laparoscopic appendectomy in the early afternoon the same day. Findings at surgery were uncomplicated (non-perforated) appendicitis. The patient was discharged home within hours of completion of the procedure on the same calendar day as admission. The care the patient would have received at a lower level of care would have been identical to that which she 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.

The literature uniformly considers appendectomy for non-perforated appendicitis (uncomplicated appendicitis) including in the pediatric population as an outpatient procedure.

Frazee noted laparoscopic appendectomy in adults can be performed as outpatient with a high degree of success. In this study of 563 patients' 86% were performed as outpatient without overnight stay. Of the 79 patients who were admitted; 32 were for pre-existing conditions and 31 because of lack of transportation, leaving only 16 (3%) who were admitted for postoperative morbidity or physician discretion. Only seven patients (1.2%) required readmission after being discharged from outpatient surgery for appendicitis. Similar standards are applied in children and adolescents with acute appendicitis who should have even higher success rates for outpatient procedures because of absence of medical co-morbidities.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient. 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. In this case the patient was discharged within hours of completion of the surgical procedure. 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's appeal of denial of inpatient admission by its agent is based on the premise that inpatient admission was medically necessary. The agent states, "the patient's admission was medically necessary and in accord with the standard of care for acute appendicitis requiring preoperative stabilization, intravenous hydration, and intravenous antibiotics." This is inaccurate. In fact, standard of care as noted in the peer-reviewed literature and standard of practice is that appendectomy in the pediatric population for uncomplicated appendicitis is considered ambulatory. The hospital cites the MCG (Milliman Care Guidelines) guideline for Pediatric General Admission criteria citing "emergency inpatient surgery," and Ambulatory Surgery exception for preoperative situation, condition or finding that warrants inpatient stay as indicated by 1) inpatient care needed for preoperative disease or condition (cited conditions are diagnostic assessment, preoperative hydration, pain control, and intravenous antibiotics) and 2) emergent surgery. Neither of the cited guidelines is the appropriate Milliman Care Guideline for the treatment of pediatric appendicitis. The Milliman Care Guideline which should be used is that specific to a diagnosis or disease. The more appropriate MCG (Milliman Care Guidelines) guideline is the procedure specific guideline titled "Appendectomy, without Abscess or Peritonitis, by Laparoscopy, Pediatric" (P-20) which considers appendectomy for uncomplicated appendicitis an ambulatory procedure. The fact that the procedure is unscheduled does not equate with a surgical emergency. The literature uniformly supports that appendectomy for uncomplicated appendicitis can be performed as an outpatient procedure.

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 care the patient would have received at a lower level of care than acute inpatient would have been identical to that which she received. The anticipated length of stay following appendectomy in a pediatric patient is < [less than] 24 hours. In this case, it was less than 4 hours. 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 necessary to provide safe postoperative treatment.