Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute appendicitis
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female transferred from one facility to another facility for management of acute appendicitis. Computed tomography (CT) scan done at the transferring facility showed a seven millimeter appendix with slight enhancement of the wall with two appendicoliths. The diagnosis was "minimal" acute appendicitis. There were no signs suggestive of perforated appendicitis. White blood cell count was elevated to 20,000 with left shift. Antibiotics were ordered at the outside hospital (unclear if they were given). 

The patient arrived in the late afternoon. The patient was admitted to acute inpatient level of care and subsequently admission was re-ordered. Admission orders included nothing by mouth, intravenous fluids and antibiotics, and pain control. A pelvic ultrasound was ordered which was done which was unremarkable except for a trace amount of free fluid.  

The patient underwent laparoscopic appendectomy the following morning. Findings were acute non-perforated appendicitis. The patient was discharged following surgery. Discharge orders were entered in the postoperative orders. 

The acute inpatient level of care was denied as not medically necessary. This review is for the hospital's appeal of the denial of the acute inpatient level of care. The hospital ,through its agent filed the appeal of the denial of the acute inpatient level of care on behalf of the hospital. The agent states that the management of acute appendicitis could not be safely managed at a lower level of care or on an outpatient basis. The hospital further states that inpatient admission is "in accord with standard of care for acute appendicitis requiring preoperative stabilization, intravenous hydration and intravenous antibiotics." The agent also cites Milliman Care Guideline for Pediatric General Admission Criteria that admission is indicated for emergency inpatient surgery and Ambulatory Exception stating that admission is indicated for an emergent procedure. The hospital also does not consider emergency surgery ambulatory.

No, the treatment (i.e. inpatient level of care) was not medically necessary. The care rendered did not require acute inpatient level of care.

The patient is a female. The patient had been evaluated at another facility where she was diagnosed with appendicitis on computed tomography scan. White blood cell count was elevated with left shift. A pelvic ultrasound was ordered after arrival which showed no evidence of ovarian pathology. The patient was admitted to acute inpatient level of care. The patient was made nothing by mouth, ordered for antibiotics, and intravenous fluids. Plan was to perform an appendectomy the following day.  

The following morning, the patient underwent laparoscopic appendectomy.  The operative report is not provided but the findings suggest acute appendicitis without evidence of perforation. The operation was less than 40 minutes in duration. The patient was discharged home within hours of completion of the procedure. Discharge orders were included in the postoperative orders. 

The care the patient would have received at a lower level of care would have been identical to that which she received. The most appropriate level of care for appendectomy for non-perforated acute uncomplicated appendicitis is ambulatory. 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. 

Laparoscopic appendectomy for non-perforated appendicitis can safely be performed as outpatient with or without overnight observation. It was determined the patient had appendicitis before her admission and that she would undergo appendectomy which was deferred to the following morning. The literature uniformly considers appendectomy for non-perforated appendicitis (uncomplicated appendicitis) including in the pediatric population as an outpatient procedure. Deferring appendectomies until the following day is standard but is only for the convenience of the surgeon and hospital to avoid operations in the middle of the night. 

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%) 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%). 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 = standard deviation) 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."

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 affect 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. In this case the adolescent patient was discharged within 15 hours of admission and within two hours after completion of the procedure. Indications for inpatient admission would be findings of perforated or in some cases gangrenous appendicitis. Neither condition was suspected at the time the decision to admit. There was no other reasonable condition, treatment or monitoring which required inpatient admission. 

The hospital, through its agent has appealed the denial of the acute inpatient level of care. The hospital's agent states that the management of acute appendicitis could not be safely managed at a lower level of care or on an outpatient basis. No specific reason is given to support this claim. The hospital further states that inpatient admission is "in accord with standard of care for acute appendicitis requiring preoperative stabilization, intravenous hydration and intravenous antibiotics." Contrary to this statement, inpatient admission is not considered standard of care for acute appendicitis. The literature uniformly supports that appendectomy for uncomplicated appendicitis can be performed as an outpatient procedure. Preoperative stabilization other than perhaps a fluid bolus in the Emergency Department is unnecessary. Preoperative antibiotics can be given in the Operating Room prior to incision. The agent also cites Milliman Care Guideline for Pediatric General Admission Criteria that admission is indicated for emergency inpatient surgery and Ambulatory Exception stating that admission is indicated for an emergent procedure. She also cites that the hospital does not consider emergency surgery ambulatory.  

The Milliman Guideline (MCG) states that admission is indicated for emergency inpatient surgery. In this case, the operation was deferred until the following day which is not consistent with a true emergency. No valid reason is cited why the stated care could not have been rendered at a lower level of care than acute inpatient. The Milliman Care Guidelines (MCG) for Pediatric General Admission Criteria cited that admission is indicated for emergency inpatient surgery is not the appropriate guideline for pediatric appendicitis. The guideline which should be used is that specific to the diagnosis or disease. The more appropriate Milliman Care Guidelines (MCG) 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 fact that the surgery was not done for more than 14 hours after initial presentation to the emergency room (ER) is not consistent with an emergency surgical 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. 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.