Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Epigastric abdominal pain, nausea, and vomiting
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient is a teenage female that presented to the hospital with a two to three day history of epigastric abdominal pain, nausea, and vomiting. The patient had no fever. Her white blood cell count was not elevated. The patient underwent computed tomography (CT) scan which showed mild acute appendicitis. There were no findings suggestive of perforation. The patient's medical history was significant for severe obesity, hypertension, and pre-diabetes. The patient was admitted to acute inpatient level of care in the pediatric ward and scheduled for laparoscopic appendectomy that evening. The operative report describes a straightforward uncomplicated laparoscopic appendectomy. Surgical findings were acute uncomplicated appendicitis with a small amount of free fluid. Subsequent pathology showed "mild acute appendicitis." Postoperatively, the patient was transferred to the Pediatric Intensive Care Unit around midnight. According to the note, intravenous antibiotics were discontinued shortly after surgery. Intravenous acetaminophen was ordered for pain and morphine for severe pain. Clear liquid diet was ordered postoperative. The following morning the patient was advanced on diet. Intravenous fluids and medications were discontinued that following day and the patient was discharged home. The acute inpatient admission was denied for lack of medical necessity. The hospital has appealed the denial which is the basis for this review. 

The inpatient level of care was not medically necessary.

The care rendered did not require acute inpatient level of care.
The patient was a teenage female that presented with a two to three day history of epigastric abdominal pain, nausea, and vomiting. The patient underwent evaluation that extended into the morning of the next day. The patient underwent computed tomography scan which showed mild acute appendicitis. There were no findings suggestive of perforation. The patient's medical 
history was significant for severe obesity, hypertension, and pre-diabetes. The patient was admitted to acute inpatient level of care and scheduled for laparoscopic appendectomy that evening. The patient underwent laparoscopic appendectomy late in the evening. The operative report describes a straightforward 
uncomplicated laparoscopic appendectomy. Subsequent pathology showed "mild acute appendicitis." Postoperatively, the patient was transferred to the Pediatric Intensive Care Unit. There were no valid indications for the intensive care unit (ICU) level of care. 
According to the note, intravenous antibiotics were discontinued shortly after surgery. Intravenous acetaminophen was ordered for pain and morphine for severe pain. There are no records the patient required morphine for pain. Clear liquid diet was ordered postoperatively and was advanced to regular diet several hours later. The patient was discharged on the next day. The care rendered did not require acute inpatient level of care. The care the patient would have received at a lower level of care would have been identical to that which she received. The most 
appropriate level of care for appendectomy for non-perforated acute uncomplicated appendicitis is ambulatory. Laparoscopic appendectomy for non-perforated appendicitis can safely be performed as outpatient with or without overnight observation. Postoperative antibiotics are not indicated after appendectomy for uncomplicated appendicitis and the surgical team recommended that they be discontinued.