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 female who presented to the Emergency Department with a 12-hour history of abdominal pain. The patient's past medical history is positive for asthma, attention deficit hyperactivity disorder, adjustment disorder, and learning disability. 

On examination the patient had suprapubic abdominal pain. The white blood cell count was elevated to 18,300 with left shift (87% polymorphonuclear leukocytes). Ultrasound did not visualize the appendix. Computed tomography (CT) scan diagnosed the patient with appendicitis without evidence of perforation (uncomplicated appendicitis). Surgery was consulted and determined the patient would undergo open appendectomy. The patient received an intravenous fluid bolus, intravenous antibiotics, and was made 'nothing by mouth' (NPO). 

The patient was admitted to acute inpatient level of care.  The patient underwent appendectomy with findings of fibrinopurulent appendicitis with localized peritonitis. Intraoperative cultures were taken. The patient was treated with triple antibiotics after surgery pending culture results. Culture results reported showed no growth. 

The patient was kept 'nothing by mouth' (NPO) overnight after the surgery. The following morning, she was tolerating diet and reported minimal pain. The patient had no fever. White blood cell count on postoperative day #1 was 12,100. That night, the patient was advanced to full liquid diet. White blood cell count was 10,400. 

The patient was discharged home with seven days of oral antibiotics. The acute inpatient admission / level of care was denied as not medically necessary. This review is for an appeal of the prior denial.  The hospital's appeal states the denial for the services in question is unreasonable and appropriate clinical judgment was exercised by the treating team of physicians. The appeal cites InterQual criteria for Pediatric General Surgery with peritonitis. A second appeal states the patient required inpatient management of "severe, progressively worsening nausea, vomiting and abdominal pain." The appeal states that the care rendered was not possible in an outpatient setting. Both InterQual and Milliman Care Guidelines are cited for meeting criteria for 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 underwent open appendectomy that same day. Findings at surgery were uncomplicated (non-perforated) fibrinopurulent appendicitis with local peritonitis. Intraoperative cultures (which are not uniformly considered indicated in pediatric appendicitis) were taken. The patient was continued on intravenous triple antibiotics after the surgical procedure. Postoperative antibiotics after appendectomy for uncomplicated appendicitis are not considered indicated. Post-operative daily laboratory monitoring is generally not indicated, and triple antibiotics are no longer the standard of care. 

On postoperative day #1, the patient was afebrile, had minimal pain and was tolerating diet. The patient could have been discharged with or without oral antibiotics the same day or the next day. The postoperative care, length of hospitalization, is not consistent with standard care for pediatric uncomplicated appendicitis. 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. 

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%) 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. 

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 patient was discharged two days after the surgical procedure. The postoperative antibiotics, laboratory monitoring, duration of 'nothing by mouth' (NPO) and slow advancement of diet are inconsistent with standard of care for the treatment of uncomplicated appendicitis in the pediatric population. 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 cites Milliman Care Guidelines (MCG Health) for necessary inpatient admission. The appropriate and specific Milliman Care Guideline which should be used is that specific to a diagnosis or disease. That guideline titled "Appendectomy, without Abscess or Peritonitis, by Laparoscopy, Pediatric" (Page 20) 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.

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 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.