Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Laparoscopic appendectomy
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a male that presented with a one-day history of abdominal pain, fever (reported prior to arrival), and anorexia. Vital signs were normal on presentation. The patient had a one-time low grade elevated temperature of 99.8oF in Emergency Department. Abdomen was soft to palpation on examination without documented peritonitis. White blood cell count was mildly elevated to 14,940. Sodium was 133 milliequivalents per liter. Ultrasound showed a dilated tip of the appendix measuring 1.2 centimeters with trace surrounding fluid. The child received intravenous antibiotics, intravenous fluids and Tylenol and was scheduled for laparoscopic appendectomy that day. The patient was admitted to acute inpatient level of care prior to the procedure.

Single incision laparoscopic appendectomy was performed later that day. The findings were acute non-perforated / non-gangrenous appendicitis. The child was discharged within hours after the procedure. 

The hospital's appeal of denial of inpatient admission by its agent, is based on the premise that inpatient admission was medically necessary. The agent states, "the patient's admission was medically necessary and in accord with the standard of care for acute appendicitis requiring preoperative stabilization, intravenous hydration, and intravenous antibiotics. The hospital cites the Milliman Care Guidelines (MCG) for Pediatric General Admission criteria citing "emergency inpatient surgery," and Ambulatory Surgery exception for preoperative situation, condition or finding that warrants inpatient stay as indicated by 1) inpatient care needed for preoperative disease or condition (cited conditions are diagnostic assessment, preoperative hydration, pain control, and intravenous antibiotics) and 2) emergent surgery.

No, inpatient level of care was not medically necessary.
The patient is a male.  His white blood cell count was elevated with left shift. Ultrasound diagnosed the patient with appendicitis. The patient was made nothing by mouth (NPO), administered antibiotics, and intravenous fluids and scheduled for laparoscopic appendectomy. The patient was admitted to acute inpatient level of care prior to the surgical procedure.  The patient underwent laparoscopic appendectomy that afternoon. Findings at surgery were uncomplicated (non-perforated) appendicitis. The patient was discharged home within hours of completion of the procedure on the same calendar day as admission. 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. 

Laparoscopic appendectomy for non-perforated appendicitis can safely be performed as outpatient with or without overnight observation. Generally accepted practice guidelines for treatment of acute appendicitis without perforation in the pediatric population is considered outpatient with a short period observation postoperatively in some cases. The literature uniformly considers appendectomy for non-perforated appendicitis (uncomplicated appendicitis) including in the pediatric population as an outpatient procedure.

Yes, the health plan acted reasonably with sound medical judgment in denial of the 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 and would not compromise the best interests of this patient.

Appendectomy for uncomplicated appendicitis in children is considered ambulatory in most cases. In this case the patient was discharged within hours of completion of the surgical procedure. Indications for inpatient admission would be findings of perforated or in some cases gangrenous appendicitis. Neither condition was believed present preoperatively nor found at surgery.

The hospital's appeal of denial of inpatient admission by its agent, is based on the premise that inpatient admission was medically necessary. The agent states, "the patient's admission was medically necessary and in accord with the standard of care for acute appendicitis requiring preoperative stabilization, intravenous hydration, and intravenous antibiotics." This is inaccurate. In fact, standard of care as noted in the peer-reviewed literature and standard of practice is that appendectomy in the pediatric population for uncomplicated appendicitis is considered ambulatory. The hospital cites the Milliman Care Guidelines (MCG) for Pediatric General Admission criteria citing "emergency inpatient surgery," and Ambulatory Surgery exception for preoperative situation, condition or finding that warrants inpatient stay as indicated by 1) inpatient care needed for preoperative disease or condition (cited conditions are diagnostic assessment, preoperative hydration, pain control, and intravenous antibiotics) and 2) emergent surgery. Neither of the cited guidelines is the appropriate Milliman Care Guideline for the treatment of pediatric appendicitis. The Milliman Care Guideline which should be used is that specific to a diagnosis or disease. The more appropriate MCG (Milliman Care Guidelines) is the procedure specific guideline titled "Appendectomy, without Abscess or Peritonitis, by Laparoscopy, Pediatric" (P-20) which considers appendectomy for uncomplicated appendicitis an ambulatory procedure. The fact that the procedure is unscheduled does not equate with a surgical emergency. The literature uniformly supports that appendectomy for uncomplicated appendicitis can be performed as an outpatient procedure.

A lower level of care than acute inpatient would not have changed the care the patient received and would not adversely affect the health outcome for this child. The care the patient would have received at a lower level of care than acute inpatient would have been identical to that which he received. The anticipated length of stay following appendectomy in a pediatric patient is less than (< ) 24 hours. In this case, it was less than four hours. Acute inpatient level of care was not the appropriate level of care for this diagnosis, procedure, or this patient's care. Acute inpatient care was in excess of the level of care which necessary to provide safe postoperative treatment.