Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute Appendicitis

Treatment: Inpatient Admission

The insurer denied the inpatient admission. The denial was upheld.   

This is a young male patient with a history of a duplication cyst of the left kidney. He presented to the Emergency Department (ED) with complaints of abdominal pain with three episodes of diarrhea that began the night prior to presentation. His presenting temperature was 101. Laboratory work up was performed that revealed a white blood cell (WBC) count was 12.7. A physical examination was performed revealing tenderness in the right lower quadrant (RLQ) without guarding. An ultrasound of the appendix was done that revealed a suspicion for acute appendicitis. He was made nothing by mouth (NPO) and received intravenous (IV) fluids and antibiotics. He underwent a laparoscopic appendectomy without complications. After a period of medical stability he was discharged home.

As per MCG- Health Inpatient and Surgical Care 23rd Edition Appendectomy, Uncomplicated, Open or Laparoscopic ORG: P-20 (ISC) the Operative Status Criteria is ambulatory for most children with acute, uncomplicated, nonperforated appendicitis and those undergoing interval appendectomy after nonoperative treatment. It is inpatient for children with complicated appendicitis (e.g. perforated without generalized peritonitis) or for those requiring prolonged (e.g., more than 24 hours postoperatively) care after surgery (e.g., co morbid illness). The goal length of stay is ambulatory or 1 day postoperative. Extended Stay as defined by Minimal (a few hours to 1 day), Brief (1 to 3 days), Moderate (4 to 7 days), and Prolonged (more than 7 days) may be needed for: Prolonged fever and prolonged fever may require longer observation in hospital on parenteral antibiotics and one can expect brief stay extension; Complicated appendicitis with discovery or development of generalized peritonitis or intra-abdominal abscess may require longer observation on parenteral antibioticsNone of these situations were seen in this case as the patient had an uncomplicated non-perforated appendicitis as noted and did not have any complication post- surgery. The patient could have been cared for under an observation status (ambulatory setting) and therefore did not require an acute care inpatient admission. 

MCG also noted that there are multiple studies that document length of stay of 1 day or less. For example, MCG noted "A multicenter observational study of 2617 pediatric patients with acute appendicitis (73% simple) and found a median length of stay of 1 day for both laparoscopic and open appendectomies. Another study of 360 pediatric patients with uncomplicated appendicitis who underwent laparoscopic appendectomy found a mean length of stay of 23 hours. A study of 92 pediatric patients who underwent laparoscopic appendectomy for uncomplicated appendicitis found that 92% of patients were able to be discharged in less than 24 hours, with a mean length of stay of 14 hours. Analysis of 295 pediatric patients undergoing appendectomy (82% laparoscopic) for uncomplicated appendicitis after the implementation of a clinical pathway found a mean length of stay of 24 hours. Analysis of national hospital discharge data for a pediatric population shows 72% of hospitalized patients undergoing a principal procedure of laparoscopic appendectomy for acute appendicitis without mention of peritonitis discharged in 1 day." Thus, a laparoscopic appendectomy can be done under an observation status with discharge within 23 hours of surgery. There was no reason or indication for the patient to stay beyond a 23-hour stay or to be admitted for an acute inpatient admission.

The health care plan did act reasonably and with sound medical judgment and in the patient's best interest.  

Based on the above, the medical necessity for the inpatient hospital is not substantiated.  The insurer's denial is upheld.