Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vomiting; abdominal pain. 
Treatment: Inpatient admission. 

The insurer denied the inpatient admission. 
The denial is upheld. 

The patient is a female. She presented to the hospital with a one-day history of vomiting and abdominal pain. The patient had been seen at an outside hospital where a CT (computed tomography) was done which did not visualize the appendix. White blood cell count at the outside hospital was elevated to 23,000. The patient was made NPO (nothing by mouth) and administered antibiotics at the first hospital and transferred to the treating hospital. 

The patient was febrile on arrival (Temperature=101.8). Ultrasound done that morning showed acute uncomplicated appendicitis. The patient was admitted to acute inpatient level of care. Admission orders included NPO (nothing by mouth) status, intravenous fluids, intravenous antibiotics and analgesia medication. The patient was scheduled for laparoscopic appendectomy to be done that day. The patient underwent single port laparoscopic appendectomy that afternoon on the date of admission. The surgical findings were acute uncomplicated appendicitis without perforation or gangrenous changes. There was some fibrinous exudate on the appendix. 

The operative report describes a straightforward laparoscopic appendectomy for uncomplicated appendicitis. The patient was discharged from the post-anesthesia recovery area. Records indicate the patient was transferred to the operating room from the emergency department. There is no indication the patient was ever transferred to the ward. Postoperative orders included regular diet and oral analgesia medication. Intravenous fentanyl (narcotic) was ordered by anesthesia in the Recovery Room area. The patient did not receive postoperative antibiotics or labs (contrary to documentation in the hospital's appeal letter).  The child was discharged to home from the post-anesthesia recovery area. 

Coverage of the acute inpatient admission was denied by the health plan as not medically necessary. This review is for an appeal of the previous denial of the acute inpatient level of care. 

The hospital's appeal notes that inpatient admission was required for the emergent procedure and that management of acute appendicitis could not be safely managed at a lower level of care or in the outpatient setting. Reasons cited are that the child required postoperative monitoring of labs, intravenous antibiotics and intravenous pain medication and specialty consultation. In support, cited is Milliman Care Guideline Ambulatory Surgery Exception for emergent procedure requiring general admission AND inpatient care required for an emergent procedure requiring diagnostic assessment, pre-operative hydration, surgical clearance and postoperative monitoring of labs, intravenous antibiotic therapy and intravenous pain medication. 

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

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient. 

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 endanger the patient's health or safety and would not compromise the best interests of this patient. 

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. 

Reasons cited are that the child required postoperative monitoring of labs, intravenous antibiotics and intravenous pain medication and specialty consultation. In support, the appeal letter cites Milliman Care Guideline Ambulatory Surgery Exception for emergent procedure requiring general admission AND inpatient care required for an emergent procedure requiring diagnostic assessment, pre-operative hydration, surgical clearance and postoperative monitoring of labs, intravenous antibiotic therapy and intravenous pain medication. 

The hospital's appeal states that inpatient admission was required for the emergent procedure and that management of acute appendicitis could not be safely managed at a lower level of care or in the outpatient setting. The appeal cites Milliman Care Guideline for Ambulatory Surgery Exception for emergent procedure requiring general admission AND inpatient care required for an emergent procedure requiring diagnostic assessment, pre-operative hydration, surgical clearance and postoperative monitoring of labs, intravenous antibiotic therapy and intravenous pain medication. The cited guideline is not the appropriate Milliman Care Guideline (MCG) 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 guideline is the procedure specific guideline titled "Appendectomy, without Abscess or Peritonitis, by Laparoscopy, Pediatric" (Page 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 appeal inaccurately notes the child required postoperative monitoring of labs, intravenous antibiotics, and intravenous pain medication and specialty consultation. In fact, the child did not require or have monitoring of postoperative labs and did not receive postoperative antibiotics. Neither is indicated for postoperative care of uncomplicated appendicitis. 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 she received. The anticipated length of stay following appendectomy in a pediatric patient is < [less than] 24 hours. In this case, it was less than 3 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 was necessary to provide safe postoperative treatment.