Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Right lower quadrant abdominal pain
Treatment:  Inpatient admission
The Inpatient admission was not medically necessary.

The patient is a male that presented to Cohen Children's Hospital in the afternoon.  He was evaluated in the Emergency Department.  Ultrasound was consistent with diagnosis of appendicitis.  The hospital through its agent states that a CT was ordered (the results are not provided).  This was unnecessary, given the positive ultrasound findings.  The patient was diagnosed with appendicitis and admitted for planned appendectomy later that day. 

The appendectomy was performed the following afternoon, approximately 11 hours post-admission.  The patient underwent a straightforward two port laparoscopic appendectomy which was completed around 14:00 that day.  The findings were an inflamed enlarged appendix without mention of perforation or gangrene (according to the hospital's appeal letter).  The patient was discharged home within hours of completion of the surgical procedure. 

The care that 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 treatment of non-perforated acute uncomplicated appendicitis is ambulatory.  There was a time interval from admission until the surgical procedure of approximately 11 hours.  It is standard to defer appendectomy until the following daylight hours for the convenience of the surgeon and hospital.  The preoperative overnight stay was not out of medical necessity but rather for convenience.  None of the preoperative care required an acute inpatient level of care.  Generally accepted practice guidelines for treatment of acute appendicitis without perforation in pediatric population is an 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 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.  Laparoscopic appendectomy for non-perforated appendicitis can safely be performed as outpatient with or without overnight observation.  The adolescent patient underwent a straightforward laparoscopic procedure for uncomplicated 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 he received in fact.  It is in excess of the level of care which is necessary to provide safe postoperative treatment.  
Appendectomy is not a true emergency. It is routinely deferred until daylight hours, which is inconsistent with an emergency procedure.  The fact that the procedure is unscheduled does not make the procedure an emergency.  The fact that the procedure was not performed until the following afternoon, over 12 hours after presentation is not consistent with an emergent operation.