Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pectus Excavatum
Treatment: inpatient admission
The insurer denied coverage for inpatient admission.
The denial is upheld.

This is an adult with a history of idiopathic short stature (ISS), pectus excavatum, and bilateral video assisted thoracoscopic surgery (VATS) with bilateral Nuss bar placement. The patient was admitted. The patient had a past medical history of idiopathic short stature, growth hormone therapy and pectus excavatum. The patient was post bilateral video assisted thoracoscopic surgery (VATS) Nuss bar and stabilizing bar. The patient felt well and presented for CXR (x-ray) with no acute findings. The plan was Nuss bar removal. 

An anesthetic block was placed by anesthesia. The American Society of Anesthesia status was II. The patient underwent Nuss bar removal. The patient was admitted to a telemetry step down for pectus excavatum postop care. Surgical sites and neurovascular sites were assessed. The patient was given intravenous (IV) fluids and IV Ancef. They were discharged after a period of medical stability. 

The insurer noted that to approve this service the following criteria must be met: The patient did not have a condition or finding before surgery that required an inpatient stay as shown by 1 or more of the following: inpatient care needed for preop disease or condition (infection, problem with blood clotting, change in behavior, dangerous irregular heartbeat, abnormal vital signs which included blood pressure, heart rate, breathing rate, temperature and oxygen level); emergent procedure; complex surgical approach or situation anticipated; procedure is not low risk and the patient is at high anesthetic risk; presence of drug related risk preop; use of any medications or drugs that may interact with the anesthetic; inadequate outpatient care situation. The patient did not have an event, condition, or finding during or after surgery that warranted inpatient stay as indicated by 1 or more of the following: heart or breathing not normal or near status before surgery; vital signs that were not within normal range; acute decrease in kidney function; severe electrolyte abnormalities; altered mental status that is severe or persistent; temperature not as expected; ambulatory or appropriate activity level status not yet achieved; operative site complication; postop effects not resolved or adequately managed. The patient did not have complicating features requiring inpatient care as indicated by 1 or more of the following: severe complications of procedure; extensive or prolonged surgery; change to open or complex procedure; malignant hyperthermia; other complicating feature requiring inpatient care.

The patient does not meet criteria for inpatient admission as the procedure performed could have been done in an ambulatory setting with 23-hour observation according to Milliman Care Guidelines (MCG) General Recovery Care- 26th edition Ambulatory surgery or procedure. Potentially ambulatory surgery or procedure covered by this guideline (i.e., not covered more specifically by another guideline) may proceed on an ambulatory basis due to the  absence of ambulatory surgery exception criteria, as indicated by ALL of the following: No inpatient care needed for clinically significant preoperative disease or condition; Complex surgical approach or situation not anticipated; Low-risk procedure or patient not at high anesthetic risk; No drug-related risk; No inadequate outpatient care situation. 

Finally, MCG General recovery care 26th edition Ambulatory surgery exception criteria notes that potentially ambulatory procedure or surgery warrants inpatient care due to 1 or more of the following: Inpatient care needed for clinically significant preoperative disease or condition; Complex surgical approach or situation anticipated; Procedure is not low risk and patient at high anesthetic risk; Presence of drug-related risk; Inadequate outpatient care situation; Postoperative event, condition, or finding that warrants inpatient stay. 

Considering the above criteria, the patient did not warrant inpatient status as there was no concern for a clinically significant preop disease or postop disease. 

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the inpatient is upheld. Medical Necessity is not substantiated.