Diagnosis: Acute Appendicitis

Treatment: Inpatient Admission

The insurer denied the Inpatient Admission. The denial was upheld.

This patient is a young female who presented to the emergency department (ED) in early 2019 for right sided abdominal pain and four episodes of diarrhea. She has a history of hypothyroidism. Her physical exam was significant for right lower quadrant and right upper quadrant tenderness. She was afebrile with stable vital signs. An abdominal ultrasound revealed acute appendicitis. She was maintained nothing by mouth (NPO) started on intravenous (IV) fluid and antibiotics (IVAB) and prepared for surgery. The patient underwent an uneventful laparoscopic appendectomy for non-perforated acute appendicitis. She was monitored in the Post Anesthesia Care Unit (PACU) and then discharged home after a period of stability.

As per Milliman Care Guideline (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, non-perforated appendicitis and those undergoing interval appendectomy after non-operative 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 antibiotics; Complications such as wound infection, intra-abdominal abscess, fecal fistula, pylephlebitis, and intestinal obstruction may occur and require continued observation or reoperation or postoperative bleeding may require reoperation and one can expect brief to moderate stay extension; Prolonged ileus with prolonged ileus may delay initiation of feeding and one can expect brief stay extension. None of these situations were seen in this case as the patient had an uncomplicated non-perforated appendicitis.