Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Tonsillectomy and adenoidectomy surgery
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission.
The denial is upheld.

This is the case of a patient with a history of familial intrahepatic cholestasis with liver transplant 1 year ago, hypertension, seizures, cytomegalovirus (CMV), gastrostomy tube dependence, tonsillitis, and asthma. As per the operative note the patient underwent tonsillectomy and adenoidectomy. The patient was observed in the Post Anesthesia Care Unit (PACU) for several hours and noted to have several episodes of apnea. As such he was admitted for observation.

Given the complex medical history the decision was made to keep the patient overnight for close observation post operative monitoring. He was monitored in the PACU for several hours without apneic events before being transferred to the floor where he arrived awake and stable on room air and was admitted.

Ear, Nose and Throat (ENT) progress note indicated the tonsil bed was dry and there was no evidence of active bleeding or oozing. The patient was tolerating oral liquids without issues. The patient was cleared for discharge. Pediatric progress note indicated no events reported overnight- no apnea or desaturations. The patient was cleared for discharge by ENT.

Based upon the records, acute inpatient admission was not justified as this patient could not have been managed in an ambulatory/observation setting with observation and discharged within a 23-hour observation status. According to Milliman Care Guideline (MCG) General recovery care 26th edition Ambulatory surgery exception criteria GRG:CG-AEC (ISC GRG) 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.

In addition MCG General recovery care 26th edition Head and Neck Surgery or procedure GRG:SG-HNS (ISC GRG) the Operative Status Criteria is Ambulatory: for most eye, middle ear, inner ear, or nose surgeries; Some pharyngeal airway procedures for sleep apnea; Most biopsy procedures; Most simple drainage procedures without drain in place; Most major dental procedures; Operations for hearing loss; Cleft palate or lip operations; Most vocal cord operations; Many cyst or sinus remnant operations; Epistaxis control with ALL of the following: No posterior packing; No procedures endangering airway; Tonsillectomy or adenoidectomy (or both) without complication (e.g., hemorrhage). In addition MCG notes that discharge criteria include Continued inpatient stay is needed until 1 or more of the following are present: Acceptable patient status for next level of care is achieved; ALL of the following are present: Operative site and other wounds acceptable; Pain and nausea absent or adequately managed; Temperature status acceptable; No infection, or status acceptable; Ocular status acceptable; Orbital edema or inflammation absent or controlled; Airway and swallowing status acceptable; Activity level acceptable; Intake acceptable; No inpatient interventions needed; General Discharge Criteria met. He did not have surgical complication that required inpatient status.

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

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