Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cough, fever, and surgical site pain s/t appendectomy
Treatment: Inpatient admission
The Inpatient admission was not medically necessary.

The patient is a female that underwent laparoscopic appendectomy two days prior to presentation. She was discharged home on the date of surgery. The patient returned to the ER two days later in the evening with complaints of fever, cough, and intermittent abdominal pain at the surgical site. The cough had been present for one week and preceded the appendectomy. 

The patient's fever in the ER was elevated to 100.3oF. White blood cell count was elevated to 18,800 with left shift. CRP (C-reactive protein) was normal at 0.7. Pulse was elevated at 133 beats per minute. Physical examination showed mild tenderness at the incision site without swelling or redness. Chest x-ray was negative for infiltrate. Ultrasound done on the next day was unremarkable and did not show a drainable fluid collection. Surgery was consulted at 02:00 and recommended admission with intravenous antibiotics. Diagnosis was upper respiratory infection and febrile illness after appendectomy. 

The patient was admitted by Pediatrics to acute inpatient level of care, made NPO (nothing by mouth), and ordered for intravenous antibiotics. On the day after presentation, white blood cell count was down trending (13,500). The patient had no documented fever. The patient was ordered for regular diet. On the day of discharge, white blood cell count was normal (6500). She was discharged home with oral antibiotics. Discharge was completed at 16:16. 

The patient is a female that underwent laparoscopic appendectomy. The preoperative CT showed a marginally dilated appendix consistent with early appendicitis. No operative report is provided, but based on the fact that the patient was discharged home on the date of surgery, the surgery was necessarily straightforward, and the appendix was not perforated or gangrenous. The patient returned to the ER two days later in the evening with complaints of fever, cough, and intermittent abdominal pain at the surgical site. The cough had been present for one week and preceded the appendectomy, suggesting that the patient had a respiratory infection prior to the appendectomy. Temperature in the ER was only mildly elevated to 100.3oF (fever considered > 101.5oF), but the patient's mother reported higher fevers at home.  White blood cell count was significantly elevated to 18,800 with left shift. CRP was normal at 0.7. Pulse was elevated at 133 beats per minute. Physical examination showed mild tenderness at the incision site without swelling or redness. Tenderness along the incision would be expected following a recent surgical procedure. Chest x-ray was negative for infiltrate. Ultrasound done was unremarkable. Surgery was consulted and recommended admission with intravenous antibiotics. Diagnosis was upper respiratory infection and febrile illness after appendectomy. 

Later that same morning, the patient had defervesced and the white blood cell count was down trending in less than 12 hours after the initial white blood cell count. The initial elevated white blood cell count was probably more indicative of dehydration given the rapid correction.  The patient had no documented fever throughout the short hospitalization. On the day after presentation, the patient was ordered for regular diet. On the day of discharge, white blood cell count was normal, the patient was tolerating diet and was discharged home. 

Monitoring for the reasons cited (worsening fever, dehydration, and infection) does not require inpatient level of care for a short period of observation. 

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. This lower level of care would not have compromised the best interests of this patient.