Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient presented to the emergency department with a diagnosis from an outside hospital of appendicitis. He had a history of a fever and a cough for one day and a temperature of 103 degrees Fahrenheit at home. He had some respiratory symptoms including wheezing and two prior episodes of vomiting and one episode of diarrhea two days prior to his presentation. He had tenderness in the right lower quadrant on exam and a computed tomography (CT) scan of the abdomen demonstrated thickened wall of the appendix concerning for appendicitis. Evaluation in the emergency department further revealed a positive test for respiratory enterovirus and he was treated in the emergency room with fluids, antibiotics, and methylprednisolone for his wheezing. On the same day of admission, he was taken to the operating room for a laparoscopic appendectomy which was completed in an uncomplicated fashion and his recovery was also uneventful with the exception of one more dose of steroids for wheezing. His pain control was good. He was discharged from the hospital in good condition on the day following the operation.
At issue is the medical necessity of an inpatient stay.
An acute inpatient level of care was not appropriate or medically necessary. The patient could have been safely and appropriately managed at a lower level of care.
An inpatient stay could be justified if there was complicated appendicitis (eg., perforated appendicitis with generalized peritonitis), an untoward perioperative event, intraoperative injury or complication, inadequate physiologic recovery, hemodynamic instability, acute organ injury, persistent altered mental status, fever or other signs of septic complications, surgical site complication, management of complex comorbid medical condition or a finding of an occult or new medical condition. His respiratory condition did not result in hypoxia, was in good control with anti-inflammatory medications, and did not require a longer stay.
Surgical treatment of otherwise healthy pediatric patients with acute nonperforated appendicitis is usually provided at a lower level of care. No evidence presented in the appeal documentation or in the primary medical records would indicate that the patient had complicated appendicitis.
In one study authored by Aguayo et.al., in over 500 cases, approximately 28% (n=128) were discharged on the day of surgery. Of the remaining patients, 12.9% (number [n] =59) stayed overnight for medical reasons, 0.4% (n=2) stayed for social reasons, 3.9% (n=18) stayed because the operation ended late in the evening, and 82.8% (n=381) stayed because of clinical care habits. Compared with patients who stayed overnight, there was no statistically significant difference in readmission rates (0.7% versus 1.9%, probability (P)=0.6%), follow-up before scheduled appointment (5.4% versus 5.4%, P=1.0), and complication rate (0.7% versus 2.6%, P=0.3). Patients whose operation ended later in the day had a longer hospital stay. Thus, same day discharge is safe for children undergoing laparoscopic appendectomy for nonperforated appendicitis. These data strongly suggest that for most patients with acute, nonperforated appendicitis who undergo an uncomplicated appendectomy, a lower level of care thereafter is appropriate since their needs are low acuity and the recovery is generally smooth and uneventful.
Based on the literature and widespread experience with modern treatment of pediatric acute appendicitis, an inpatient acute level of care is not justified for acute, uncomplicated appendicitis. If patients have evidence of physiologic compromise that would indicate medical necessity for a higher acuity of care, it should be evident in the records.