Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain (s/p laparoscopic appendectomy)
Treatment: Inpatient admission
The insurer denied the inpatient admission. 
The denial is upheld.

No, the Inpatient admission was not "medically necessary".

The patient is a female that presented to the hospital in the early morning hours on  with CT findings concerning for appendicitis. The patient had been seen at another facility where the patient had a CT scan, which was concerning for appendicitis. The patient was administered antibiotics prior to transfer. The patient reported a one day history of abdominal pain, nausea, vomiting, diarrhea, and fever. White blood cell count was not elevated (5800). Ultrasound done showed a mildly enlarged partially compressible appendix with prominent wall and slight hyperemia. There was trace abdominal fluid. The findings were "equivocal for acute appendicitis." The patient was admitted to acute inpatient level of care while still in the Emergency Department. The patient went from the ED to the operating room.

The patient underwent uneventful single site laparoscopic appendectomy. Findings were "mild early acute appendicitis" without evidence of perforation. An incidental finding was a 2 cm right ovarian cyst, which was not manipulated. The procedure was 46 minutes in duration with 90 minutes of anesthesia time. Postoperatively, the patient was ordered for clear liquid diet to advance as tolerated. No postoperative antibiotics were ordered. The patient was discharged from the post-anesthesia care area shortly after the procedure.  

The acute inpatient level of care was denied as not medically necessary. The hospital through its agent reports the patient was tachycardic with a heart rate of 101 bpm (beats per minute). The hospital has appealed the denial stating that inpatient level of care was appropriate under Milliman Care Guidelines as an Ambulatory Surgery Exception because the patient underwent an emergent procedure. In support of inpatient admission, the hospital reports the patient was tachycardic (P=101) and required admission for preoperative assessment, medical clearance, and optimization of the patients physical status in preparation for surgery. 

The patient could have been treated at a lower level of care without adversely affect the quality of care delivered or endanger the patient's health or safety and would not compromise the best interests of this patient.

Appendectomy for non-perforated appendicitis is considered ambulatory. Generally accepted practice guidelines for treatment of acute appendicitis without perforation in pediatric population 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 patient underwent a laparoscopic procedure for uncomplicated appendicitis. The hospital, through its agent, states inpatient admission was required for preoperative assessment, medical clearance, and optimization of the patient's physical status in preparation for surgery. In response, a healthy patient does not require preoperative medical clearance. Preoperative assessment was done in the ER as part of the evaluation and does not require inpatient level of care. The patient received intravenous fluids and antibiotics during the evaluation in the ED, and could have undergone appendectomy at any time after the diagnosis was confirmed. The hospital's appeal does not address why care could not have been accomplished at a lower level of care. The reported mild tachycardia of 101 bpm (beats per minute) with normal be <=100 beats per minute is not an indication for admission. The hospital's agent cites Milliman Care Guidelines Ambulatory Surgery Exception Criteria in support of the acute inpatient level of care stating that criteria for acute inpatient setting for an otherwise ambulatory procedure is indicated when the preoperative situation, condition or findings warrants inpatient because the procedure was emergent. The more appropriate Milliman Care Guideline titled "Appendectomy, Uncomplicated, Open or Laparoscopic, Pediatric" (P-20) considers appendectomy for uncomplicated appendicitis as an ambulatory procedure. Appendectomy for uncomplicated appendicitis is not a true emergency. It is routinely deferred until daylight hours as was done here, which is inconsistent with an emergency procedure. The fact that the procedure is unscheduled does not make the procedure an emergency. . She was discharged within hours of the procedure from the post-anesthesia care area on the same day as the operative procedure.  The literature uniformly considers appendectomy for non-perforated appendicitis (uncomplicated appendicitis) in adults as an outpatient procedure. The same standards would apply to adolescents undergoing appendectomy for non-perforated appendicitis.