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 who presented with abdominal pain and fever which began the previous day. The parents reported episodes of emesis. 

The patient was tachycardic and febrile in the Emergency Department. Physical examination showed tenderness in the right lower part of the abdomen. White blood cell count was noted to be 21,000 with left shift (increased neutrophils). Ultrasound did not visualize the appendix. Computed tomography (CT) was positive for appendicitis without findings of perforation. Surgery was consulted. Antibiotics were started in the Emergency Department and patient was scheduled for an appendectomy the following morning. 

The patient was admitted under Pediatrics to acute inpatient level of care. The following day, the patient underwent laparoscopic appendectomy with findings of acute non-perforated appendicitis. Postoperative orders included continuation of antibiotics. Regular diet was ordered. The patient was discharged the following morning with a five-day course of oral antibiotics. 

The acute inpatient level of care was denied as not medically necessary. The hospital has appealed the denial of acute inpatient care which is the subject of this review. The plan's denial states the patient could have been monitored in observation [level of care]. The interventions provided during the time after surgery were appropriate for the observation setting.  The hospital has appealed the denial of the acute inpatient admission. The appeal letter reiterates the patient's history and concludes that inpatient services were appropriate. The appeal states that notations made by the medical staff in the medical records support the necessity of the services provided as inpatient level of care.

No, inpatient level of care was not medically necessary. The care rendered did not require acute inpatient level of care.
The patient is a male who presented with a one-day history of fever, vomiting and abdominal pain. The child was noted to have an elevated white blood cell count and right lower quadrant abdominal pain on examination. Ultrasound was inconclusive for findings of appendicitis and computed tomography was ordered for diagnosis. The computed tomography was completed that afternoon and showed acute appendicitis without findings of abscess or perforation. 

The patient was admitted under Pediatrics to acute inpatient level of care. Admission orders included nothing by mouth (NPO) status, intravenous fluids, intravenous antibiotics and analgesia medication. The patient was scheduled for laparoscopic appendectomy to be done the following day rather than that evening. It is common to defer appendectomy until the following day when diagnosis is made in the evening but in this case, it was only for convenience that was deferred until the following day. The following day the patient underwent laparoscopic appendectomy. The surgical findings were acute uncomplicated appendicitis without perforation.  The operative report describes a straightforward laparoscopic appendectomy for uncomplicated appendicitis. The patient was continued on intravenous antibiotics after surgery and was discharged the following day on five days of oral antibiotics. Antibiotics after appendectomy for non-perforated appendicitis are generally considered unnecessary. There may have been concern about the high white blood cell count and fever such that discharge on oral antibiotics may have been warranted.  Postoperative orders included regular diet. 

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. Even with postoperative antibiotics, had appendectomy been done on the day of presentation, the patient would have only required one post-midnight stay. Generally accepted practice guidelines for treatment of acute appendicitis without perforation in the pediatric population is considered outpatient with a short period observation postoperatively in some cases.  The literature uniformly considers appendectomy for non-perforated appendicitis (uncomplicated appendicitis) including in the pediatric population as an outpatient procedure.

Benedict, et al. conducted a study for same day discharge in children after laparoscopic appendectomy. The study included evaluation of discharge success, duration of hospital stay, and readmission rates. A total of 569 children were included, with 87% discharged home the same day as their appendectomy. Of the patients discharged home the same day of surgery, their median length of postoperative stay was four hours compared with 19 hours for the patients who stayed overnight. Approximately two-thirds of patients who had their appendectomies after 6 PM stayed overnight. In addition, patients discharged home the same day had similar hospital readmission rates compared with patients who stayed overnight (2% versus 4%). The authors concluded, "after laparoscopic appendectomy in children with nonperforated appendicitis, same day discharge not only reduces postoperative length of stay but also is not associated with higher hospital readmission rates."

Yes, the health plan acted reasonably with sound medical judgment in denial of the acute inpatient level of care. 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 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 diagnosis of appendicitis was but appendectomy was deferred until the following day. The care rendered did not require acute inpatient level of care.  Indications for inpatient admission would be findings of perforated or in some cases gangrenous appendicitis. Neither condition was believed present preoperatively nor found at surgery.

The hospital's appeal concludes that based on notation by the medical staff that inpatient care was appropriate. No rationale is provided as to why the identical care was not appropriate at a lower level of care. The Milliman Care Guideline (MCG) titled "Appendectomy, without Abscess or Peritonitis, by Laparoscopy, Pediatric" (P-20) considers appendectomy for uncomplicated appendicitis an ambulatory procedure. The literature uniformly supports that appendectomy for uncomplicated appendicitis can be performed as an outpatient procedure.

A lower level of care than acute inpatient would not have changed the care the patient received and would not adversely affect the health outcome for this child. The care the patient would have received at a lower level of care than acute inpatient would have been identical to that which he received. 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. Acute inpatient care was in excess of the level of care which necessary to provide safe postoperative treatment.