Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male. He presented to the Emergency Department with right lower quadrant abdominal pain suspicious for appendicitis.

The patient was noted to have mildly elevated white blood cell count of 12,300 with left shift (increased neutrophils). Past medical history significant for Asperger syndrome and disruptive dysregulation disorder. An initial ultrasound was inconclusive. Repeat ultrasound later that night showed a dilated and non-compressible tubular structure which was deemed suspicious for acute appendicitis.

The patient was admitted to acute inpatient level of care. The patient was ordered NPO (nothing by mouth), and for intravenous fluids and antibiotics for presumed appendicitis.  It was determined the next day that the structure imaged on ultrasound may not be the appendix and therefore a CT (computed tomography) scan was ordered. CT (computed tomography) scan was done in the morning reported acute uncomplicated appendicitis without evidence of perforation or abscess.

The patient underwent laparoscopic appendectomy later that day. The operative report describes a straightforward laparoscopic appendectomy for uncomplicated appendicitis. The procedure was completed. There were no findings of gangrenous change or perforation of the appendix.

Postoperatively, the patient was transferred to the post-anesthesia care unit. Regular diet was ordered. The patient did not receive or require postoperative antibiotics. He was discharged home after a short stay in the post-anesthesia care unit, less than two hours after completion of the surgery.

The hospital through its agent states that inpatient level of care is supported by MCG (Milliman Care Guidelines) guidelines for Pediatric General Admission Criteria. The cited guideline is that admission is indicated for emergency inpatient surgery. The cited reasons for inpatient admission were pre-operative stabilization, IV (intravenous) hydration and IV (intravenous) antibiotics. The agent states this was within standard of care and that the patient could not have been managed safely at a lower level of care. No reason is provided why the care could not be proffered at a lower level of care with the same interventions and expected outcomes.

No, the Inpatient admission was not medically necessary and not standard of care. The care rendered did not require acute inpatient level of care.

The patient underwent laparoscopic appendectomy.  The findings were acute appendicitis without evidence of perforation. The patient was discharged home within hours of completion of the procedure. 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 after the CT (computed tomography) scan was done and would require appendectomy. The literature uniformly considers appendectomy for non-perforated appendicitis (uncomplicated appendicitis) as an outpatient procedure.

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. In this case the adolescent patient was discharged within 16 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 was made. There was no other reasonable condition, treatment or monitoring which required inpatient admission.

Additional reasons cited to inpatient level of care were need for preoperative medical stabilization, IV (intravenous) hydration and IV (intravenous) antibiotics. None of these interventions require acute inpatient level of care. In this case, the patient underwent a prolonged diagnostic workup which resulted in over a 24 hour period until the patient underwent the operative procedure. Preoperative stabilization other than a fluid bolus and antibiotics if the surgery is not being done immediately is all that is required. No valid reason is cited why the stated care could not have been rendered at a lower level of care than acute inpatient. It was stated that inpatient level of care was consistent with standard of care and implied that these services were not available other than in an outpatient setting. In fact, the overwhelming literature about standard of care for pediatric appendicitis is that uncomplicated appendicitis can be cared for as outpatient or in some cases with an overnight stay (observation level of care). The MCG Guideline for Pediatric General Admission Criteria cited that admission is indicated for emergency inpatient surgery is not the appropriate guideline for pediatric appendicitis. The more appropriate MCG "Milliman Care Guideline" guideline is the more specific guideline titled "Appendectomy, Uncomplicated, Open or Laparoscopic, Pediatric" 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 admission and over 24 hours after initial presentation to the ER (emergency room) 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.