Appeal type: Medical necessity
Decision: Upheld

Digestive System/Gastrointestinal
Inpatient Hospital

Diagnosis: Acute Appendicitis
Treatment: Inpatient Stay
The insurer denied the inpatient stay.
The health plan's determination is upheld.

The patient is a female who presents to the emergency department complaining of abdominal pain for the past several days. Her pain is rated 8 out of 10 associated with nausea and vomiting. The physical examination shows right lower quadrant tenderness positive McBurney's sign. The white count is normal. The computed tomography (CT) scan of the abdomen and pelvis shows enlarged appendix measuring 12.5 millimeters (mm), peri-appendiceal inflammation without any perforation. The patient underwent a laparoscopic appendectomy without any complications. She was transferred to the floor. Her pain was well controlled and she tolerated a diet. The patient was discharged.

The requested health service/treatment of inpatient stay was not medically necessary for this patient. The patient did not have any intra operative complications. She was discharged the following day after her surgery. The patient did not require inpatient status as she underwent her surgical procedure and was discharged less than 48 hours from admission.
Previous observational studies have demonstrated the safety of discharging patients after laparoscopic appendectomy within the same day without hospitalization. The application of Enhanced Recovery After Surgery (ERAS) guidelines has resulted in shorter length of stay, fewer complications, and reduction in medical costs. The aim of this study was to investigate if ERAS protocol implementation in patients with acute uncomplicated appendicitis decreases the length of stay enough to allow for ambulatory laparoscopic appendectomy.
Methods: In this prospective, randomized controlled clinical trial, 108 patients were randomized into two groups: laparoscopic appendectomy with ERAS (LA-E) or laparoscopic appendectomy with conventional care (LA-C). The primary endpoint was postoperative length of stay. The secondary end points were time to resume diet, postoperative pain, postoperative complications, re-admission rate, and reoperation rate.
Results: From January 2016 through May 2017, 50 patients in the LA-E group and 58 in the LA-C were analyzed. There were no significant differences in preoperative data. Regarding the primary end point of the study, the ERAS protocol significantly reduced the postoperative length of stay with a mean of 9.7 hours (h) (standard deviation (SD): 3.1) versus 23.2 h (SD: 6.8) in the conventional group. The ERAS protocol allowed ambulatory management in 90 percent (%) of the patients included in this group. There was a significant reduction in time to resume diet (110 versus 360 minutes) and less moderate-severe postoperative pain (28 versus 62.1%) in the LA-E versus LA-C group. The rate of complications, readmissions, and reoperations were comparable in both groups.
Conclusions: ERAS implementation was associated with a significantly shorter length of stay, allowing for the ambulatory management of this group of patients. Ambulatory laparoscopic appendectomy is safe and feasible with similar rates of morbidity and readmissions compared with conventional care. (Avila 2019.) 

The health plan's determination is upheld in whole.