Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Thyroid cancer
 
Treatment: Inpatient admission

The insurer denied coverage for inpatient admission. The denial is reversed. 

This patient is a male with a diagnosis of right thyroid nodules and papillary thyroid cancer, who was admitted under the Ear, Nose, and Throat (ENT) service.  He has a family history of thyroid cancer.  The plan of care included Nothing by Mouth (NPO) and intravenous fluids. He underwent a scheduled procedure which involved a total thyroidectomy, central compartment lymph node dissection and a continuous intraoperative vocal cord monitoring.  The planned surgery was a thyroid lobectomy, but masses were discovered intra-operatively.  This changed the surgical plan to a total thyroidectomy.  Based on the operative report, the patient tolerated the procedure well and was taken to recovery in excellent condition.  Post-operatively, the patient received pain medication, albumin, calcium and Synthroid.  His calcium levels were 9.4, 9.7, and 9.  There were no acute events following the operation, and his neck wound was clean, dry, and intact with a dressing.  The patient was discharged with medication prescriptions for levothyroxine and oxycodone.

The health plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The planned surgery was a thyroid lobectomy, but masses were discovered intra-operatively. This changed the surgical plan to a total thyroidectomy.  Given the increased risks of hemorrhage, laryngeal nerve paralysis, respiratory compromise, and hypocalcemia overnight monitoring was in the patient's best interest.

The American Thyroid Association supports outpatient thyroidectomy in only a small subset of carefully chosen patients with extensive pre-op planning.  This case does not meet those guidelines. (American Thyroid Association 2012). According to Perera, A. H., et al. (2014), "The main barriers to short stay thyroidectomy are haemorrhage, bilateral recurrent laryngeal nerve palsy causing respiratory compromise and hypocalcaemia." Balentine, C. J., & Sippel, R. S. (2016) state, "Outpatient thyroid surgery is controversial because of concerns over life-threatening cervical hematoma." Lastly, according to the American Thyroid Association (2015), "Most patients are admitted to the hospital for at least one night following thyroid surgery.  Ambulatory thyroid surgery, defined as patient discharge to home on the same day as surgery, has become more common in the past decade.  For highly selected patients, ambulatory thyroid surgery is believed to be safe when the risk of complications is low and the patient can obtain additional medical care when necessary".

The inpatient admission is medically necessary for this patient. Medical literature supports a short stay after thyroidectomy due to the risks of hemorrhage, vocal cord paralysis, respiratory compromise, and hypocalcemia.  These issues are more readily identified in the hospital setting. If stable overnight, discharge in the morning is appropriate, which was done in this case.

The carrier's denial of coverage for the inpatient admission is reversed.  The medical necessity is substantiated.