Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute appendicitis
Treatment: Inpatient admission
The inpatient admission was not medically necessary.

The patient is a female that presented upon transfer to Cohen Children's Hospital in the early morning hours. CT done at an outside hospital (transferring facility) showed appendicitis. There was no mention of suspected rupture. The patient was admitted to acute inpatient level of care and scheduled for appendectomy later that morning. The patient underwent laparoscopic appendectomy, which was completed around 11:30 AM that day. The operative report describes a straightforward procedure less than one hour in duration. The findings were acute non-perforated appendicitis. The patient was discharged home within hours of the procedure. 

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 treatment of non-perforated acute uncomplicated appendicitis is ambulatory. Generally accepted practice guidelines for treatment of acute appendicitis without perforation in pediatric population is that the procedure is considered outpatient with a short period observation in some cases. The care does not require acute inpatient level of care.  

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

Appendectomy for non-perforated appendicitis is considered ambulatory. Laparoscopic appendectomy for non-perforated appendicitis can safely be performed as outpatient with or without overnight observation. The patient underwent a straightforward laparoscopic procedure for uncomplicated appendicitis in the morning and was discharged within six hours after completion of the procedure. The literature uniformly considers appendectomy for non-perforated appendicitis in adults as an outpatient procedure. The same standards would apply to children / adolescents undergoing appendectomy for non-perforated appendicitis.

The acute inpatient level of care would not have changed the care the patient received postoperatively, and the alternative outpatient (observation level of care) would not adversely affect the health outcome for this adolescent patient. The anticipated length of stay following appendectomy in a pediatric patient is less than 24 hours. Acute inpatient level of care is 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 she received in fact.  It is in excess of the level of care which is necessary to provide safe postoperative treatment.  

The hospital through its agent states inpatient services were required because the patient received preoperative antibiotics and needed a urine culture. In response, a single dose of preoperative antibiotics are standard for uncomplicated appendectomy. The fact that the admission orders included intravenous antibiotics was solely because the appendectomy was being deferred until the daylight hours for the convenience of the surgeon and the hospital staff. Regarding urine culture, this was unnecessary. Dysuria is common with appendicitis. Furthermore, culture results would not even become available for generally 48 hours and would not delay the surgical procedure. None of the surgeon's notes mention that a urine culture was pending or necessary prior to the appendectomy. The nurse states that the brief stay extension is necessary because the urine culture was pending. However, the patient in fact did not have a delay in discharge and urine culture would not have been back prior to discharge. Furthermore, a urinalysis could have readily excluded a urinary tract infection without need to await culture results.