Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male. He presented to the emergency department in the late evening  with abdominal pain. The patient reported vomiting and subjective fevers.

On physical examination the patient was mildly tachycardic to 102 beats per minute. White blood cell count was 12,400 with left shift. Abdominal ultrasound to evaluate for appendicitis was indeterminate. CT (computed tomography) done demonstrated a dilated appendix with surrounding inflammation without evidence of perforation. The impression was "acute uncomplicated appendicitis."

The patient was admitted to acute inpatient level of care. The patient was scheduled for laparoscopic appendectomy. Intravenous fluids and antibiotics were ordered. The patient underwent a straightforward single incision laparoscopic appendectomy. The operative report describes acute appendicitis without evidence of perforation. Postoperatively the patient was continued on intravenous fluids. Regular diet was ordered. The patient was discharged after the surgery on the same calendar day. 

The acute inpatient level of care was denied by the Insurer as not medically necessary. The hospital has appealed the denial of the inpatient level of care citing through its agent, that emergent management of acute appendicitis could not be safely managed at a lower level of care or in an outpatient setting. Reasons cited to inpatient level of care were need for emergency surgery, preoperative medical stabilization, IV (intravenous) hydration and IV (intravenous) antibiotics. Nurse Hughes cites MCG (Milliman Care Guidelines) for Pediatric General Admission Criteria: "Emergency inpatient surgery" and MCG (Milliman Care Guidelines) "Ambulatory Surgery Exception" that a potentially ambulatory procedure or surgery warrants inpatient care for a preoperative situation, condition, or finding that warrants inpatient stay: "Inpatient care needed for preoperative disease or condition emergent procedure."

This review is an appeal initiated by the hospital for the denial of the acute inpatient admission / level of care.

No, the Inpatient Hospital Admission was not medically necessary. The care rendered did not require acute inpatient level of care.

The patient is a male that presented to the emergency department. White blood cell count was mildly elevated with left shift. Appendicitis was suspected. Ultrasound done in the early morning hours was inconclusive. CT (computed tomography) was done later that morning which confirmed a diagnosis of uncomplicated appendicitis. There were no findings to suggest perforation. The patient was evaluated by surgery and admitted to acute inpatient level of care with plan for laparoscopic appendectomy. The patient was made NPO (nothing by mouth), ordered for antibiotics, and intravenous fluids. The patient underwent appendectomy that evening. The findings were acute appendicitis without evidence of perforation. The patient was discharged home within hours of completion of the procedure and on the same day. The care 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. 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 after the CT (computed tomography) scan was done and would require appendectomy. The literature uniformly considers appendectomy for non-perforated appendicitis (uncomplicated appendicitis) as an outpatient procedure.

In response to the hospital's appeal stating inpatient level of care was necessary because emergent management of acute appendicitis could not be safely managed at a lower level of care or in an outpatient setting. This is inaccurate. Appendicitis is not a surgical emergency. The fact that it is unscheduled does not equate with a surgical emergency. The fact that the surgery was not done for almost 12 hours after diagnosis is not consistent with an emergency surgical procedure. Other reasons cited to inpatient level of care were need for preoperative medical stabilization, IV (intravenous) hydration and IV (intravenous) antibiotics. None of these interventions require acute inpatient level of care. The patient had mild tachycardia on presentation but no other unstable vital signs. Preoperative stabilization other than a fluid bolus and antibiotics if the surgery is not being done immediately are required. No valid reason is cited why the care could not have been rendered at a lower level of care than acute inpatient. Optimization of the patient's medical condition did not require the half-day period until surgery could be done. Deferring appendectomy that presents in the night until daylight hours is well-established in the medical literature as safe; however its role is only for convenience of the hospital and surgeon.

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. 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.