Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain, nausea, vomiting, and diarrhea
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female.  She had presented with abdominal pain, nausea, vomiting, and diarrhea. The patient had been seen two days prior and was sent home after receiving a gastrointestinal "GI" cocktail with diagnosis of viral syndrome. 

Upon her return to the emergency department, the patient had normal vital signs. She was not tachycardic and had no fever. Laboratory evaluation revealed an elevated white blood cell count of 26,500. Ultrasound of the abdomen did not visualize the appendix. The patient underwent computed tomography (CT) scan which, on preliminary read, did not visualize the appendix or identify secondary signs of appendicitis. The patient was initially admitted to observation level of care. 

Subsequent read by the Radiologist the following morning identified the diagnosis as appendicitis (appendix nine millimeters with indistinct wall). Surgery was consulted and the decision to perform laparoscopic appendectomy was made by the surgery team. The patient underwent laparoscopic appendectomy later that day. At surgery, the appendix was unremarkable excepted for some serosal injection (described as 'reactive'). The surgical findings were not suggestive of appendicitis. Pus was noted in the Pouch of Douglas and the uterus appeared inflamed suspicious for pelvic inflammatory disease. The ovaries and Fallopian tubes were normal. The surgery was stated to be "uncomplicated." 

Postoperatively, the patient was admitted to acute inpatient level of care. Gynecology was consulted for management of pelvic inflammatory disease and recommended antibiotic treatment. Cultures of vaginal fluid were positive for gonorrhea.  The patient's pain improved over the three day postoperative period and the white blood cell count steadily declined. White blood cell count was 15,300 trending downward to 10,300 and 6200. Trans-abdominal ultrasound showed no tubo-ovarian abscess. The patient was discharged home with oral antibiotics for treatment of pelvic inflammatory disease. 

The acute inpatient level of care was denied as not medically necessary. This review is pursuant to an appeal of the previous denial of the inpatient stay/level of care.

The hospital, through its agent, has appealed the denial of the acute inpatient level. The agent incorrectly states the computed tomography (CT) showed acute appendicitis and that the patient was taken urgently to operating room (OR).  The appeal states, "given the findings of acute appendicitis complicated by concurrent pelvic inflammatory disease, and need for intravenous antibiotic treatment, inpatient conversion was warranted." It is further stated that the inpatient level was warranted because "the acuity of care required for safe and effective post procedural management was judged to substantially higher than was anticipated, with need for escalation in the level of care beyond that expected for the procedure."

No, the inpatient level of care was not medically necessary.  The patient did not require acute inpatient level of care for the care rendered.

The patient had been seen two days earlier and had been discharged from the emergency department (ED). The patient underwent an ultrasound which was non-diagnostic. The patient subsequently underwent a computed tomography (CT) scan which was read as normal on preliminary read. The following morning, the Radiologist reported the appendix was nine millimeters with indistinct wall which was consistent with diagnosis of appendicitis. There were no findings suggestive of perforation or abscess.  The patient was scheduled for appendectomy which was done later that day. The laparoscopic appendectomy was completed and revealed what looked to be a normal appendix with reactive inflammatory changes. There was pus in the pelvis and the uterus was inflamed suggestive of pelvic inflammatory disease which likely led to the findings of the appendix. Gynecology was subsequently consulted and confirmed the diagnosis of pelvic inflammatory disease. Cultures were positive for gonorrhea. 

The treatment for gonorrhea is a single intravenous (or intramuscular) dose of antibiotics followed by a course of antibiotics. Treatment according to this protocol does not require inpatient stay. Thus the three day postoperative stay for treatment of pelvic inflammatory disease was in excess of that which is standard of care for treatment of pelvic inflammatory disease and following an appendectomy for removal of a normal appendix.  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 or appendicitis or removal of a normal appendix is ambulatory. Generally accepted practice guidelines for treatment of pelvic inflammatory disease discovered during laparoscopy for suspected appendicitis acute appendicitis in the pediatric population is the procedure is outpatient with a short period observation in some cases. 

Laparoscopic appendectomy for removal of a normal appendix 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 interpreted in the morning and that she would require appendectomy. The literature uniformly considers appendectomy for non-perforated appendicitis (uncomplicated appendicitis) as an outpatient procedure. The fact that the patient was found to be suffering from pelvic inflammatory disease did not warrant a three day acute inpatient stay. 

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

The patient underwent appendectomy for suspected appendicitis. Appendicitis was not encountered but the patient had findings suggestive of pelvic inflammatory disease which was subsequently confirmed on exam and cultures positive for gonorrhea. Both conditions are considered ambulatory. Diagnostic laparoscopy without or without appendectomy (for non-perforated appendicitis) is routinely performed outpatient. Pelvic inflammatory disease is treated as outpatient in nearly all cases with initial intravenous or intramuscular antibiotic followed by oral antibiotics. Indications for inpatient admission would be findings of perforated or in some cases gangrenous appendicitis. In this case the patient did not have appendicitis but had reactive changes of the appendix because of the pelvic inflammation.  

The hospital states on appeal that the patient was taken urgently to operating room (OR). The patient was not taken to the operating room for 12 hours after arrival and until the reread of the computed tomography scan which showed uncomplicated appendicitis. The appeal states, "given the findings of acute appendicitis complicated by concurrent pelvic inflammatory disease, and need for intravenous antibiotic treatment, inpatient conversion was warranted." In response, the patient did not have findings of acute appendicitis and treatment of uncomplicated pelvic inflammatory disease only requires a single intravenous dose of antibiotics and not prolonged intravenous antibiotics therapy. The appeal states the acuity of care required for safe and effective post procedural management was judged to substantially higher than was anticipated, with need for escalation in the level of care beyond that expected for the procedure. The acuity of care was based on the newly entertained diagnosis of pelvic inflammatory disease which is an outpatient condition. 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 with discharge on an oral antibiotics regimen. 

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 she received without compromise of the patient safety or quality of care rendered. Acute inpatient care was in excess of the level of care which necessary to provide safe postoperative treatment following a negative appendectomy and antibiotic therapy for pelvic inflammatory disease.