Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Severe abdominal pain, nausea, and vomiting
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male that presented to the hospital with severe abdominal pain, nausea, and vomiting. The symptoms began two days prior to presentation. The patient presented with normal vital signs and was afebrile. Physical examination showed tenderness in the right lower quadrant of the abdomen. White blood cell count was elevated to 15,700 with left shift. C-reactive protein (CRP) was mildly elevated to 1.7. Computed tomography scan of the abdomen and pelvis showed uncomplicated appendicitis with an appendicolith. There were no signs of gangrenous changes or perforation. 

The patient was admitted preoperatively to the acute inpatient level of care  with plans for laparoscopic appendectomy that evening.  The procedure was begun prior to midnight and completed shortly after midnight. The procedure was one hour in duration skin-to-skin. Findings were non-perforated appendix with purulent fluid in the pelvis.  Antibiotics were continued post-operatively and discontinued at discharge.  Complete blood count was checked postoperatively which showed a white blood cell count on 12,700. The patient was discharged home with oral antibiotics. 

The acute inpatient admission was denied as not medically necessary. The hospital, through its agent, has appealed the denial on the basis the adolescent member presented to the hospital with severe and progressive abdominal pain accompanied by vomiting. Physical examination revealed a tender abdomen. White blood cell count was elevated to 17,000. Computed tomography (CT) of the abdomen and pelvis demonstrated acute appendicitis without signs of perforation. The patient was ordered for intravenous analgesics, intravenous fluids, and intravenous antibiotics. The treating physician determined the patient had acute appendicitis. He underwent laparoscopic appendectomy. Postoperatively, vital signs were monitored. Diet was advanced and the patient ambulated. The hospital agent states "clearly this could not have been done in an outpatient setting." The hospital agent states, "an inpatient admission was the only reasonable course of action for this patient." The hospital agent cites Milliman Care Guideline for General Surgery or Procedure General Recovery Guideline in support of acute inpatient admission.

No, the inpatient level of care was not medically necessary. The care rendered did not require acute inpatient level of care.
The patient is a male that presented to the hospital in the late afternoon with a two-day history of abdominal pain. White blood cell count was elevated with left shift. Computed tomography (CT) scan done that evening was read as early appendicitis. The patient was made nothing by mouth (NPO), administered antibiotics, and intravenous fluids and scheduled for laparoscopic appendectomy later that evening. The patient was admitted to acute inpatient level of care prior to the surgical procedure.  The patient underwent laparoscopic appendectomy. Findings at surgery were uncomplicated (non-perforated) appendicitis with some purulent appearing fluid in the pelvis. Because of the purulent fluid, the patient was continued on intravenous antibiotics and discharged on oral antibiotics. Repeat labs checked after surgery is generally considered not necessary after pediatric appendectomy. 

This patient could have been cared for at a lower level of care than acute inpatient. 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. 

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

Frazee noted laparoscopic appendectomy in adults can be performed as outpatient with a high degree of success. In this study of 563 patients' 86% were performed as outpatient without overnight stay. Of the 79 patients who were admitted; 32 were for pre-existing conditions and 31 because of lack of transportation, leaving only 16 (3.0%) who were admitted for postoperative morbidity or physician discretion. Only seven patients (1.2%) required readmission after being discharged from outpatient surgery for appendicitis. Similar standards are applied in children and adolescents with acute appendicitis who should have even higher success rates for outpatient procedures because of absence of medical co-morbidities. 

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 6PM stayed overnight. In addition, patients discharged home the same day had similar hospital readmission rates compared with patients who stayed overnight (2% versus 4%, P = 0.155). 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."

Cairo sought to evaluate the influence of same day discharge on 30-day readmission rates following appendectomy for acute appendicitis in pediatric patients. The study was a retrospective cohort using the American College of Surgeons National Surgical Quality Improvement Program-Pediatric database to evaluate 30-day readmission rates among pediatric patients who underwent an appendectomy for acute, nonperforated appendicitis. Patients selected for inclusion were between ages zero and 17 years over a four year period. Patients excluded were those discharged more than two days after surgery. The primary outcome was 30-day readmission. Secondary outcomes included surgical-site infections and other wound complications. Of the 20, 981 patients, 4662 (22.2%) were discharged the same day and 16,319 (77.8%) were discharged within one or two days after surgery. The patient cohort included 12,860 boys (61.3%) and 8121 girls (38.7%), with a mean (SD) age of 11.0 (3.56) years. There was no difference in the odds of readmission for patients with same day discharge compared with those discharged within two days. Likewise, there was no difference in wound complication rate between patients who were discharged on the day of the procedure and those discharged one or two days after surgery. The conclusion of the large study was "in pediatric patients with acute appendicitis undergoing appendectomy, same day discharge is not associated with an increase in 30-day hospital readmission rates or wound complications when compared with discharge 1 or 2 days after surgery."

The patient could have been treated at a lower level of care without adversely affecting the quality of care delivered or endanger 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. 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, through its agent, has appealed the denial of the acute inpatient level of care. The hospital agent states "clearly this could not have been done in an outpatient setting." Outpatient setting does not mean that the patient could not be treated in an observation level of care and no reason is given why the care rendered could not have been at a lower level of care than acute inpatient. The hospital agent states, "an inpatient admission was the only reasonable course of action for this patient." This is not true. The hospital agent cites Milliman Care Guideline for General Surgery or Procedure General Recovery Guideline in support of acute inpatient admission.  This is not the appropriate guideline for pediatric appendicitis. The Milliman Care Guideline which should be used is that specific to a diagnosis or disease. The more appropriate Milliman Care Guideline is the procedure specific guideline titled "Appendectomy, without Abscess or Peritonitis, by Laparoscopy, Pediatric" (P-20) which considers appendectomy for uncomplicated appendicitis an ambulatory 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 she received. The anticipated length of stay following appendectomy in a pediatric patient is generally less than 24 hours. In this case it was a little more than 36 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.