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 male. He that presented to the hospital in the afternoon with right lower quadrant abdominal pain, nausea, and decreased appetite.

The patient's white blood cell count was 21,600 with 79% neutrophils and 3% bands. CT (computed tomography) scan was consistent with uncomplicated appendicitis. The patient received intravenous fluids, antibiotics and antinausea medication in the ER (emergency room).

Admission orders included nothing by mouth, perioperative antibiotics, intravenous fluids, and surgery later that evening. The patient underwent laparoscopic appendectomy in the evening of admission. Findings were uncomplicated appendicitis without perforation or gangrene. Antibiotics and intravenous fluids were continued postoperatively.

Postoperatively, the patient had tachycardia but no documented fever (the appeal states the patient was febrile postoperatively). Postoperative note the following day states the patient was afebrile and tachycardic. The only documentation in support of this is a one-time pulse of 106 bpm (beats per minutes) in the morning.

The patient was discharged in the afternoon the following day after the procedure.

The acute inpatient level of care was denied as not medically necessary.

The hospital through its agent has appealed the denial of the acute inpatient level of care. The basis for the denial is that inpatient level of care was medically necessary for treatment of the patient's medical condition, and that he required emergent treatment for appendicitis, and the patient could not be safely managed at a lower level of care. It is also incorrectly stated the patient was febrile and tachycardic after surgery, when in fact it was prior to surgery.

The hospital in its appeal states that the procedure qualifies for Ambulatory Surgery Exception requiring inpatient level of care under Milliman Care Guidelines (MCG Health) because the preoperative situation, condition or finding required an emergent procedure and an ambulatory setting was not available.

Also cited under the Milliman Guideline for the requirement of inpatient level of care is the postoperative event of hemodynamic instability which persists despite adequate treatment and postoperative temperature not as expected and not appropriate for outpatient follow-up.

No, the Inpatient admission was not medically necessary.
The patient is a male that presented to the hospital. White blood cell count was elevated with left shift. CT (computed tomography) scan showed a dilated appendix. The patient was made NPO (nothing by mouth), ordered for antibiotics, antiemetic medication, and intravenous fluids. The patient underwent laparoscopic appendectomy that evening. Findings were uncomplicated (non-perforated) appendicitis. The patient was admitted to acute inpatient level of care after completion of the surgical procedure.  The patient was discharged home the following afternoon, less than 24 hours after completion of the procedure. The patient received intravenous antibiotics after surgery, which is generally considered unnecessary for uncomplicated appendicitis. The care the patient would have received at a lower level of care would have been identical to that which he received. The most appropriate level of care for appendectomy for non-perforated acute uncomplicated appendicitis is ambulatory.

Laparoscopic appendectomy for non-perforated appendicitis can safely be performed as outpatient with or without overnight observation. 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. It was determined the patient had appendicitis before surgery and that he would undergo appendectomy.

The literature uniformly considers appendectomy for non-perforated appendicitis (uncomplicated appendicitis) including in the pediatric population as an outpatient procedure.

Therefore, given the above, the Inpatient admission was not medically necessary.

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 have compromised the best interests of this patient.

Appendectomy for uncomplicated appendicitis in children is considered ambulatory in most cases. In this case, the patient was discharged within 24 hours of admission. Indications for inpatient admission would be findings of perforated or in some cases gangrenous appendicitis. Neither condition was believed present preoperatively, nor was the admission order entered after surgery when it had already been determined by surgical findings that the appendix was not perforated or gangrenous.

The hospital has appealed the denial of the acute inpatient level of care. The basis for the appeal is that inpatient level of care was medically necessary for treatment of the patient's medical condition and that he required emergent treatment for appendicitis. No reason is given why this care could not have been rendered at a lower level of care. It is also stated in the appeal that the patient was febrile and tachycardic after surgery. The records provided do not substantiate this. Postoperative note by the attending surgeon the following morning states the patient had no fever after surgery. The only documented abnormal vital sign is a pulse of 106 beats per minute the following day which would not be considered abnormal. 

It is also stated that the procedure qualifies for Ambulatory Surgery Exception requiring inpatient level of care under Milliman Care Guidelines (MCG Health) because the preoperative situation, condition or finding required an emergent procedure and an ambulatory setting was not available. The Milliman Care Guideline which should be used is that specific to the diagnosis or disease. The more appropriate MCG guideline is the more specific guideline titled "Appendectomy, Uncomplicated, Open or Laparoscopic, Pediatric" (P-20) which considers appendectomy for uncomplicated appendicitis an ambulatory procedure. The fact that the procedure is unscheduled does not equate with a surgical emergency. The literature uniformly supports that appendectomy for uncomplicated appendicitis can be performed as an outpatient 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. 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.