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 presented to the ER by ambulance.  The patient reported right lower quadrant abdominal pain, and his mother reported he had passed out for about 10 seconds.  The pain began in the morning.  The patient reportedly struck his head when he passed out.  The patient reported vomiting and diarrhea. 

The patient's vital signs on arrival were temperature ranging from 97.3oF to 100.5oF and heart rate ranging from 82-111 beats per minute while in the ER.  The patient appeared ill with guarding of the right lower quadrant.  White blood cell count was 12,600 with left shift (87% neutrophils).  EKG (electrocardiogram) was normal.  The patient was given a fluid bolus, and pain medication in the ER.  Ultrasound revealed a non-compressible appendix without evidence of perforation.  Adult General Surgery saw the patient and recommended a CT.  CT showed a hyperenhancing 8 mm appendix with trace fluid suspicious for early appendicitis.  

The plan was to admit to the Pediatrics Floor under the Pediatric service.  The patient was admitted to acute inpatient level of care.  The patient was made NPO (nothing by mouth) and admitted for serial examinations.  No pain medication or antibiotics were ordered, indicating that the surgeons were not convinced the patient had appendicitis.  The discharge note states, "the patient was made NPO and admitted to the hospital for observation." 

The patient reported increasing pain.  Repeat white blood cell count was 7300 (normal) with persistent left shift (76% neutrophils).  Antibiotics were started, and the patient was scheduled for laparoscopic appendectomy.  A note stated the plan was to undergo a laparoscopic appendectomy.  The patient underwent laparoscopic appendectomy the next day.  Findings were an acute inflamed appendix without evidence of perforation. 

The patient was discharged home from the post-anesthesia care area (PACU) within hours of completion of the procedure.

The acute inpatient level of care was denied as not medically necessary.  The hospital through its agent, has appealed citing Milliman Care Guideline Ambulatory Surgery Exception: "A potentially ambulatory procedure or surgery warrants inpatient admission when the preoperative situation, condition, or finding that warrants inpatient is indicated because of an emergent procedure." 

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 serial examinations and appendectomy for non-perforated acute uncomplicated appendicitis is ambulatory.  Generally accepted practice guidelines for treatment of acute appendicitis without perforation in pediatric population is that the procedure is considered outpatient with a short period observation in some cases.  Furthermore, the delay in surgery resulted in an additional post-midnight hospital stay.  The care does not require acute inpatient level of care.  

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 < 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.  

The hospital through its agent, has appealed citing Milliman Care Guideline Ambulatory Surgery Exception:  "A potentially ambulatory procedure or surgery warrants inpatient admission when the preoperative situation, condition, or finding that warrants inpatient is indicated because of an emergent procedure."  In response, this is not the most appropriate guideline, and procedure was not emergent based on the fact that it was deferred for > 24 hours.  The fact that an operation is unscheduled does not automatically make that procedure an emergency.  Appendectomy for uncomplicated appendicitis is not a true emergency.  The more appropriate Milliman Care Guideline titled "Appendectomy, Uncomplicated, Open or Laparoscopic, Pediatric" (P-20) considers appendectomy for uncomplicated appendicitis as an ambulatory procedure.