Appeal type: Medical necessity
Decision: Upheld

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

The patient is a female transferred from one hospital to another hospital for treatment of pediatric appendicitis. The patient reported one-day history of abdominal pain, nausea, and vomiting. There was no reported fever. White blood cell count at the referring hospital was elevated to 15,200. Ultrasound at the referring hospital was non-diagnostic.  Computed tomography (CT) scan done at the referring hospital showed a dilated fluid filled appendix suspicious for but not diagnostic of acute appendicitis. 

On arrival, the patient was not tachycardic or febrile.  Ultrasound was repeated at Cohen Children's Hospital and showed a non-compressible dilated appendix consistent with appendicitis. Perforation was not suspected. The patient was made nothing by mouth (NPO), administered antibiotics and scheduled for laparoscopic appendectomy later that day. She was admitted preoperatively to acute inpatient level of care. 

The patient underwent single incision laparoscopic appendectomy. The operative report describes a straightforward procedure for uncomplicated appendicitis. The procedure was completed. The patient was discharged later that day. Regular diet was ordered postoperative and discharge order entered after surgery.

The acute inpatient admission was denied as not medically necessary. The hospital through its agent has appealed the denial. The basis for the appeal is that acute appendicitis could not be managed at a lower level of care or in an outpatient setting. The agent states the patient required preoperative stabilization, intravenous hydration, and intravenous antibiotics and that this was consistent with standard of care and implied that these services were not available other than in an outpatient setting. Milliman Care Guideline for Ambulatory Surgery Exception cited is that the preoperative situation of diagnostic assessment, preoperative assessment, pain control, and antibiotics as well as emergent appendectomy required inpatient level of care.

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

The patient is a female that presented. The patient had been seen initially at another hospital where computed tomography (CT) scan was inconclusive for appendicitis. White blood cell count obtained at the initial hospital was elevated with left shift. Appendicitis was suspected. Ultrasound was done, which was consistent with acute appendicitis. There were no findings suggestive of perforation. 

The patient was admitted to acute inpatient level of care with plan for appendectomy that day. The patient was made nothing by mouth (NPO), ordered for antibiotics, and intravenous fluids. The patient underwent single incision laparoscopic appendectomy that afternoon. The findings were acute appendicitis without evidence of perforation. The patient was discharged home within hours of 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 and would require appendectomy. The literature uniformly considers appendectomy for non-perforated appendicitis (uncomplicated appendicitis) as an outpatient procedure. 

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 uncomplicated appendicitis in children is considered ambulatory in most cases. In this case the adolescent patient was discharged within 16 hours of admission and within two 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's agent states the patient required preoperative stabilization, intravenous hydration, and intravenous antibiotics which required inpatient level of care because acute appendicitis could not be managed at a lower level of care or in an outpatient setting. Preoperative stabilization other than a fluid bolus and antibiotics if the surgery is not being done immediately is all that is required. No valid reason is cited why the stated care could not have been rendered at a lower level of care than acute inpatient. The agent states that inpatient level of care was consistent with standard of care and implied that these services were not available other than in an outpatient setting. The overwhelming literature and standard of care for pediatric appendicitis is that uncomplicated appendicitis can be cared for as outpatient or in some cases with an overnight stay (observation level of care). The Milliman Care Guidelines (MCG) Guideline for Ambulatory Surgery Exception cited is that the preoperative situation of diagnostic assessment, preoperative assessment, pain control, and antibiotics as well as emergent appendectomy required inpatient level of care. This is inaccurate. Appendicitis is not a surgical emergency. The fact that it is unscheduled does not equate with a surgical emergency. The fact that the surgery was not done for almost ten hours after diagnosis is not consistent with an emergency surgical procedure. Other reasons cited to inpatient level of care were need for preoperative medical stabilization, intravenous (IV) hydration and IV antibiotics. None of these interventions require acute inpatient level of care. 

The hospital's agent also cites Milliman Care Guidelines (MCG) Ambulatory Surgery Exception: "the preoperative situation of diagnostic assessment, preoperative assessment, pain control, and antibiotics as well as emergent appendectomy required inpatient level of care." In response, this is not the most appropriate guideline and the procedure was not emergent based on the fact that it was deferred for greater than (>) ten hours. The fact that an operation is unscheduled does not automatically make that procedure an emergency. The more appropriate Milliman Care Guideline titled "Appendectomy, Uncomplicated, Open or Laparoscopic, Pediatric" considers appendectomy for uncomplicated appendicitis as an ambulatory procedure. 

The acute inpatient level of care would not have changed the 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 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 necessary to provide safe postoperative treatment.