Appeal type: Medical necessity
Decision: Upheld

Diagnosis: s/p surgery (laparoscopic appendectomy). 
Treatment: Inpatient admission. 

The insurer denied the inpatient admission. The denial is upheld. 

The patient is an male. He presented to the Emergency Department with a two-day history of abdominal pain, nausea, and decreased oral intake. The patient was seen by his Primary Care Provider, and he was referred to the hospital. 

The patient's vitas signs on arrival were blood pressure=108/63, pulse rate=102 beats per minute, respiratory rate of 22 breaths per minute, and no fever. White blood cell (WBC) count was elevated to 16,000 with left shift. Ultrasound of the appendix showed a mildly dilated non-compressible appendix consistent with uncomplicated appendicitis. The patient was admitted to acute inpatient level of care with a diagnosis of appendicitis. He was begun on intravenous fluids, ordered for intravenous antibiotics, made NPO (nothing by mouth), and surgery consult ordered. The surgeon's note states, "I explained [to the parents] that if I found perforated or complicated appendicitis, the child would need postoperative admission to decrease the risk of developing an intraabdominal abscess." The patient was scheduled for the procedure the following day. 

The patient underwent laparoscopic appendectomy. Findings were acute appendicitis without evidence of perforation or gangrenous changes. The patient was ordered for regular diet postoperative. The patient was discharged. 

The patient did not undergo appendectomy until the following morning. No explanation is given for deferring the appendectomy until the following day, although this is common practice as a convenience for the surgeon and the hospital to avoid late night operations. 

The findings were acute appendicitis without evidence of perforation. The patient was discharged home within hours of the procedure. 

The care that the patient would have received at a lower level of care would have been identical to that which he received. The most appropriate level of care for appendectomy for non-perforated acute uncomplicated appendicitis is ambulatory. The surgeon explained to the parents if he found perforated or complicated appendicitis, the child would need postoperative admission to decrease the risk of developing an intraabdominal abscess. Generally accepted practice guidelines for treatment of acute appendicitis without perforation in 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. 

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 < 24 hours. In this case, the patient was discharged within hours of the procedure. 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 he received. Acute inpatient care was in excess of the level of care which necessary to provide safe postoperative treatment.