Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Cancer-Lung Cancer.
Treatment: Inpatient hospital stay.
The health plan denied the inpatient stay as not medically necessary. 

The reviewer has overturned in part the health plan's determination.

This patient is a patient with hypertension (HTN), diabetes mellitus (DM), and hyperlipidemia who presented with right-sided chest and back pain, sharp, constant that had begun that morning, was worse with motion with intermittent similar pain over the year prior. He also had 1 year of right flank pain. At a recent admission for hyperglycemia, he was noted to have a lung mass.  In the emergency department (ED), temperature 97.9, blood pressure (BP) 167/85, heart rate (HR) 76, respiratory rate (RR) 20, oxygen saturation (spo2) 98% room air (RA). He was comfortable, breathing comfortably with clear lungs, soft and non-tender abdomen, alert and oriented. His white blood cell count (WBC) 5.5, Sodium(Na) 137, bicarbonate 29, blood urea nitrogen (BUN) / Creatinine 17/1.05, albumin 4.0. lactate 0.8, and venous blood gas (VBG) 7.44/41.
The electrocardiogram (ECG) without ischemic changes. He was admitted to the surgical service, and cardiology and pulmonary were consulted as a resection of the mass recently found was felt necessary. Cardiology recommended an echo before surgery. Pulmonary saw the patient and recommended repeating a computed tomography (CT)scan of the thorax, obtaining Pulmonary Function Tests (PFTs) and an arterial blood gas (ABG), and check a six minute walk. Transthoracic echocardiogram (TTE)  was unremarkable. He underwent video-assisted thoracoscopic surgery (VATS) it was uneventful, he came back from operating room (OR) with a chest tube, and was hemodynamically stable. The next day he was doing well, ambulating, and his pain controlled; chest tube was placed to water seal. On the following day the chest tube was removed, and he was discharged the following day.

He did not meet any of the inpatient admission criteria for his presenting symptoms, and there were no concerning diagnoses or severe symptoms. He presented with pain and was not found to have any concerning diagnoses (acute coronary syndrome (ACS), pulmonary embolism (PE), pneumothorax, pneumonia, empyema, etc.). He was not severely ill with no encephalopathy, hemodynamic instability, respiratory distress or gas exchange abnormality, acute kidney injury or marked electrolyte abnormality. He then underwent a pre-operative evaluation for his surgery, which is typically an outpatient process.
However, once he had surgery, he needed an inpatient admission as he needed close post-operative monitoring and management including close observation of respiratory status, pain control, chest tube management, frequent chest X rays (CXRs), frequent assessment of chest tube for air leak, and these things cannot be done at a lower level of care. As such, the symptoms he presented with did not need an inpatient admission, neither did his pre-operative assessment. The patient could have been treated at a lower level of care for these dates. However, his surgical and post-surgical course did require an inpatient admission. Following thoracic surgery, patients need close monitoring for respiratory status, chest tube management, and pain control.