Appeal type: Medical necessity
Decision: Upheld

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

The patient is a female that presented with a five day history of abdominal pain. The patient denied fever or vomiting.  Past medical history was positive for mild intermittent asthma and anxiety. 

Physical examination revealed abdominal tenderness with rebound. The patient was afebrile. White blood cell count was 5300 without left shift and C-reactive protein (CRP) was less than (<) 0.4 (neither value elevated). Ultrasound for ovarian torsion showed no evidence of compromised blood flow to the ovaries. Subsequent ultrasound showed an eight millimeter appendix which was non-compressible with a small amount of surrounding fluid. There were no findings to suggest perforation. There was a question of an appendicolith. 

No, the proposed treatment, inpatient level of care, was not medically necessary.
The care rendered did not require acute inpatient level of care.

The patient is a female that presented with a five day history of abdominal pain. White blood cell count and C-reactive protein (CRP) were within normal limits. A pelvic ultrasound was ordered after arrival which showed no evidence of ovarian pathology. Ultrasound of the appendix showed an eight millimeter appendix (normal less than seven [mm]) with surrounding fluid suggestive of appendicitis. The patient was admitted to acute inpatient level of care. The patient was made nothing by mouth (NPO), ordered for antibiotics, and intravenous fluids. Plan was to perform an appendectomy later that night.  

The patient underwent laparoscopic appendectomy.  The operative report describes a straightforward appendectomy with findings suggestive of early appendicitis. The subsequent pathology report showed a normal appendix with lymphoid hyperplasia, i.e. not consistent with appendicitis. The operation was less than 45 minutes in duration. The patient was discharged home the following afternoon. Regular diet and oral analgesia was ordered after surgery. Postoperative evaluation by the resident mentions pain was well controlled. 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. Generally accepted practice guidelines for treatment of acute appendicitis without perforation in the pediatric population is the procedure is considered outpatient with a short period observation in some cases. 

Laparoscopic appendectomy for non-perforated appendicitis can safely be performed as outpatient with or without overnight observation. It was determined the patient had appendicitis before her admission and that she would undergo appendectomy. The literature uniformly considers appendectomy for non-perforated appendicitis (uncomplicated appendicitis) including in the pediatric population as an outpatient procedure. 
The patient was admitted to acute inpatient level of care prior to surgery. The patient was administered intravenous antibiotics and underwent straightforward laparoscopic appendectomy later that night. Surgical findings were a mildly inflamed appendix with distal dilation. There was no perforation and the appendix was not gangrenous. The procedure skin-to-skin was 44 minutes in duration. Subsequent pathology of the appendix showed a normal (non-inflamed) appendix with lymphoid hyperplasia. Postoperative orders included oral analgesia medication and regular diet. The patient was kept overnight and discharged home the following day. 

The acute inpatient level of care was denied as not medically necessary. The hospital has appealed the denial of the acute inpatient level of care. The basis for the appeal is that the patient required postoperative monitoring overnight after the surgical procedure. The hospital, through its attorneys, states that the overnight stay for postoperative care was not unreasonable following an appendectomy. No justification is provided as to why that care could not have been at a lower level of care than acute inpatient.

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. In this case the patient was discharged within 15 hours after the procedure but clearly could have been discharged earlier. Indications for inpatient admission would be findings of perforated or in some cases gangrenous appendicitis. Neither condition was suspected at the time the decision to admit. There was no other reasonable condition, treatment or monitoring which required inpatient admission. 

The hospital through its attorneys has appealed the denial of the acute inpatient level of care. The hospital's agent states overnight stay for postoperative care was not unreasonable following an appendectomy. No justification is provided as to why that care could not have been at a lower level of care than acute inpatient. 

The acute inpatient level of care would not have changed the care the patient received and would not adversely affect the health outcome for this adolescent patient. The care the patient received would have been identical had it been rendered at a lower level of care. The anticipated length of stay following appendectomy in a pediatric patient is less than (< ) 24 hours. Acute inpatient level of care was not the appropriate level of care for this diagnosis, procedure, or this patient's care. The care the patient would have received at a lower level of care would have been identical to that which she received. Acute inpatient care was in excess of the level of care which necessary to provide safe postoperative treatment.