Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right lower quadrant abdominal pain.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a male that presented by transfer from another facility with a one-day history of right lower quadrant pain and vomiting. Vital signs at the outside hospital and on arrival were within normal limits. The patient's physical examination showed right lower quadrant abdominal tenderness. His white blood cell count at the outside hospital was 21,800 with elevated neutrophils of 91.5%. Ultrasound at the outside hospital did not visualize the appendix.  Repeat labs after transfer showed a white blood cell count of 17,200 with 72% neutrophils, and c-reactive protein (CRP) of 5.1. General surgery evaluated the patient and recommended admission to the inpatient setting for further management. 

Inpatient admission order was entered. Admission orders included repeat ultrasound, pain control, intravenous fluids, and plan for laparoscopic appendectomy the following day. The ultrasound done the next day showed a 1.2 centimeter structure consistent with the appendix and a small amount of adjacent fluid. There was periappendiceal fat stranding but no organized fluid collection or other findings suggestive of perforation. 

The patient underwent laparoscopic appendectomy. The findings were non-perforated appendicitis. Postoperatively, the patient was ordered for regular diet. Pain control included Tylenol and ibuprofen. The patient did not require antibiotics postoperatively. The patient was discharged in the evening within a few hours of completion of the laparoscopic appendectomy. 

The acute inpatient admission was denied as not medically necessary. The hospital has appealed the denial of the acute inpatient level of care.  The hospital's appeal through its agent states the admission was medically necessary and reasonable. The hospital cites an article "by two physicians" about risk factors for perforated appendicitis citing appendiceal diameter greater than 1.1 centimeters, white blood cell count greater than 18,000, elevated c-reactive protein, and onset of symptom of abdominal pain greater than 48 hours prior to presentation. The agent states the decision for admission is based solely on the treating Practitioner's judgment at the time of evaluation.

No, inpatient level of care was not medically necessary. The care rendered did not require acute inpatient level of care.
The patient had been seen at another facility the previous day and was noted to have right lower quadrant tenderness and an elevated white blood cell count and right lower quadrant abdominal pain on examination. Ultrasound was inconclusive for findings of appendicitis. The patient was transferred to the treating facility. 

Repeat labs done showed a white blood cell count of 17,200 with 72% neutrophils, and c-reactive protein of 5.1. General surgery evaluated the patient and recommended admission to the inpatient setting for further management. The inpatient admission order was entered.  Admission orders included repeat ultrasound, pain control, intravenous fluids and plan for laparoscopic appendectomy the following day. The ultrasound done the next day showed a 1.2 centimeter structure consistent with the appendix and a small amount of adjacent fluid. There was periappendiceal fat stranding but no organized fluid collection or other findings suggestive of perforation. 

The patient underwent laparoscopic appendectomy. The findings were non-perforated appendicitis. The operative report describes a straightforward laparoscopic appendectomy for uncomplicated appendicitis. Postoperative orders included regular diet. The patient was discharged.

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. Even with postoperative antibiotics, had appendectomy been done on the day of presentation, the patient would have only required one post-midnight stay. Generally accepted practice guidelines for treatment of acute appendicitis without perforation in the pediatric population is considered outpatient with a short period observation postoperatively in some cases. The literature uniformly considers appendectomy for non-perforated appendicitis (uncomplicated appendicitis) including in the pediatric population as an outpatient procedure.

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 6 PM stayed overnight. In addition, patients discharged home the same day had similar hospital readmission rates compared with patients who stayed overnight (2% vs. 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."

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 diagnosis of appendicitis was suspected before transfer and was confirmed by ultrasound. There were no findings on ultrasound suggesting appendicitis. The patient underwent appendectomy shortly after the ultrasound confirmed the suspected diagnosis of appendicitis. The care rendered did not require acute inpatient level of care. The patient was only in the hospital on a single calendar day and for less than 18 hours.  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 through its agent states the admission was medically necessary and reasonable. No rationale is provided as to why the identical care was not appropriate at a lower level of care. The Milliman Care Guideline (MCG) titled "Appendectomy, without Abscess or Peritonitis, by Laparoscopy, Pediatric" (P-20) considers appendectomy for uncomplicated appendicitis an ambulatory procedure. 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.