Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female.  At the time of care under review, the patient had presented with a one day history of right lower abdominal pain and an episode of diarrhea. The patient was evaluated in the emergency department (ED). The patient was admitted to acute inpatient level of care 35 minutes after arrival before any labs or imaging were available. 

Ultrasound of the pelvis was negative for ovarian pathology. Following the ultrasound, the plan was to work the patient up for appendicitis with labs and a computed tomography (CT) scan. Labs showed a normal white blood cell count of 9130 and elevated C-reactive protein (CRP) of 16.5 (normal less than [<] 5).  Computed tomography (CT) scan of the abdomen and pelvis done in the early morning showed appendicitis without evidence of perforation. The emergency room (ER) Progress Note notes the patient was found to have appendicitis on computed tomography (CT) and Surgery was consulted. Surgery saw the patient and determined the patient would undergo appendectomy. The patient was ordered for nothing by mouth, intravenous fluids, and intravenous antibiotics. The inpatient admit order by Pediatrics was entered.  

The patient arrived on the Pediatric Ward. The patient underwent an eventful laparoscopic appendectomy for non-perforated appendicitis. The procedure was completed. The patient returned to the Pediatric Ward and was discharged home that afternoon. 

The acute inpatient level of care was denied as not medically necessary. This review is for an appeal of the previous denial. The hospital's basis for appeal is that the patient was considered at risk for serious adverse outcomes requiring a high level of hospital management. The hospital states the anticipated length of hospitalization was consistent with an inpatient admission and that patient required close monitoring.

No, the inpatient level of care was not medically necessary. 

The care rendered did not require acute inpatient level of care.

The patient was immediately evaluated for ovarian torsion with ultrasound. This did not reveal ovarian pathology and the appendix was not evaluated. Following the ultrasound, the patient was evaluated for appendicitis. White blood cell count was normal and C-reactive protein (CRP) was mildly elevated. Computed tomography (CT) was ordered which was not done until the early morning hours. The computed tomography (CT) revealed uncomplicated appendicitis. 

The patient was admitted to acute inpatient level of care with 35 minutes of arrival before any evaluation had been done. Therefore, at the time the admission was entered, there was not enough information to support that the patient required inpatient services or what the anticipated length of stay would be. 

A second admit to inpatient order was entered. The patient was made nothing by mouth (NPO), ordered for antibiotics, and intravenous fluids. The patient was scheduled for surgery which did not occur until the morning. The laparoscopic appendectomy was completed. The findings were acute appendicitis without evidence of perforation. The patient was discharged home that afternoon about 12 hours after the completion 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 appendectomy for non-perforated acute uncomplicated appendicitis is ambulatory. Generally accepted practice guidelines for treatment of acute appendicitis without perforation in the pediatric population is the procedure is considered outpatient with a short period observation in some cases. 

Laparoscopic appendectomy for non-perforated appendicitis can safely be performed as outpatient with or without overnight observation. It was determined the patient had appendicitis after the computed tomography (CT) scan was done in the morning and would require appendectomy. The literature uniformly considers appendectomy for non-perforated appendicitis (uncomplicated appendicitis) as an outpatient procedure. 

Frazee noted laparoscopic appendectomy in adults can be performed as outpatient with a high degree of success. In this study of 563 patients, 86% were performed as outpatient without overnight stay. Of the 79 patients who were admitted; 32 were for pre-existing conditions and 31 because of lack of transportation, leaving only 16 (3%) who were admitted for postoperative morbidity or physician discretion. Only seven patients (1.2%) required readmission after being discharged from outpatient surgery for appendicitis. Similar standards are applied in children and adolescents with acute appendicitis who should have even higher success rates for outpatient procedures because of absence of medical co-morbidities. 

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 there was a delay in the surgical procedure from the time the diagnosis of appendicitis was made by computed tomography (CT) until the operation of 22 hours. The adolescent patient was discharged within 12 hours after completion of the procedure. Indications for inpatient admission would be findings of perforated or in some cases gangrenous appendicitis. Neither condition was suspected at the time the decision to admit was made. There was no other reasonable condition, treatment or monitoring which required inpatient admission. 

The hospital states in its appeal that the patient was considered at risk for serious adverse outcomes requiring a high level of hospital management. The hospital states the anticipated length of hospitalization was consistent with an inpatient admission and that patient required close monitoring. Contrary to these assertions, there was nothing to indicate the patient was at significant risk for serious adverse outcomes. The delay in diagnosis and treatment did pose an increased risk for progression to perforated appendicitis but delaying appendectomy to the daylight hours is considered appropriate although only for convenience of the surgeon and hospital. No reasons are given why the care could not have been rendered at a lower level of care without the significant delays in both obtaining the computed tomography (CT) scan and performing the operative procedure. In fact, from the operative procedure until discharge did not involve a post-midnight stay. A lower level of care would not have changed the quality of care the patient received and would not adversely affect the health outcome for this adolescent patient. The care the patient received would have been identical had it been rendered at a lower level of care. The anticipated length of stay following appendectomy in a pediatric patient is less than (<) 24 hours. 

In this case, the patient was discharged within 12 hours of the procedure. Acute inpatient level of care was 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. Acute inpatient care was in excess of the level of care which was necessary to provide safe postoperative treatment.