Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Appendicitis
Treatment Inpatient Hospital Stay
The insurer denied the inpatient hospital stay
The determination is upheld.

This patient  presented to the emergency department with a one-day history of abdominal pain associated with non-bilious, non-bloody vomiting and a history of a fever. The patient was not toxic appearing in the emergency department, she was afebrile with a normal blood pressure and heart rate of 108. Her abdominal exam was notable for tenderness in the right lower quadrant; her white blood cell count was elevated at 22,000, and her ultrasound did not visualize the appendix leading to a computed tomography (CT) scan which showed evidence of acute appendicitis. She was taken to the operating room for an uneventful laparoscopic appendectomy, recovered well overnight and was discharged home in good condition the next day.
An inpatient hospital admission was not necessary.  The patient underwent an uneventful laparoscopic appendectomy. Patients with an acute non-perforated appendicitis like this child had can often be discharged home the same day from the hospital, without an overnight stay. The child was discharged directly from the recovery room, suggesting that the overnight stay was not necessary.  Surgical treatment of otherwise healthy pediatric patients with acute nonperforated appendicitis is usually provided at a lower level of care. No evidence presented in the appeal documentation or in the primary medical records indicated that an acute inpatient level of care was justified or necessary.
There was no diagnostic dilemma (eg., complicated appendicitis when ultrasound had been read as uncomplicated), an untoward perioperative event, intraoperative injury or complication, inadequate physiologic recovery, hemodynamic instability, acute organ injury, persistent altered mental status, fever or other signs of septic complications, surgical site complication, management of complex comorbid medical condition or a finding of an occult or new medical condition.
In one study authored by Aguayo et.al., in over 500 cases, approximately 28% (number [n]=128) were discharged on the day of surgery. Of the remaining patients, 12.9% (n=59) stayed overnight for medical reasons, 0.4% (n=2) stayed for social reasons, 3.9% (n=18) stayed because the operation ended late in the evening, and 82.8% (n=381) stayed because of clinical care habits. Compared with patients who stayed overnight, there was no statistically significant difference in readmission rates (0.7% versus 1.9%, probability [P] =0.6%), follow-up before scheduled appointment (5.4% versus 5.4%, P=1.0), and complication rate (0.7% versus 2.6%, P=0.3). Patients whose operation ended later in the day had a longer hospital stay. Thus same day discharge is safe for children undergoing laparoscopic appendectomy for nonperforated appendicitis. These data strongly suggest that for most patients with an acute, nonperforated appendicitis who undergo an uncomplicated appendectomy, a lower level of care is appropriate since their needs are low acuity and the recovery is generally smooth and uneventful.
Based on the literature and widespread experience with the modern treatment of pediatric acute appendicitis, an inpatient acute level of care is not justified for acute, uncomplicated appendicitis.