Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Facial Feminization Surgery.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

This patient is a female, assigned male at birth, who presented for an elective procedure secondary to gender dysphoria. On presentation, the patient was made nothing by mouth and started on intravenous (IV) Ancef. Under general anesthesia, the patient underwent facial feminization, hairline advancement, frontal sinus setback, medial orbital rim reconstruction and remodeling, lateral orbital rim and forehead frontal bone remodeling, bilateral brow lift, open rhinoplasty, fat grafting to the cheeks and tracheal shave with Jackson-Pratt (JP) drain placement. 

Post-procedure, the patient was transferred to the post anesthesia care unit (PACU) and subsequently admitted to the surgical floor for hemodynamic stability monitoring and pain management.  Inpatient plan of care included intravenous (IV) fluids, intravenous Ancef, intravenous Decadron, intravenous Zofran, Oxycodone, and plastic surgery consult. Once all risks were addressed and the patient achieved hemodynamic stability, she tolerated an advanced diet. The patient was cleared for discharge the following day and was scheduled to follow up as an outpatient.

No, the proposed inpatient hospital admission was not medically necessary.
According to the Milliman Care Guidelines, 25th Edition, "General Admission Criteria", Admission is indicated for one1 or more of the following:
Hemodynamic instability.
Hypertension requiring inpatient treatment.
Acute cardiac or peripheral ischemia.
Cardiac arrhythmias of immediate concern.
Severe heart failure.
Respiratory abnormalities.
Severe airflow or ventilation abnormalities.
Impending or actual respiratory arrest.
Neurologic abnormalities.
New-onset severe neurologic findings.
Suspected acute intra-abdominal process.
Severe physiologic disorder.
Abdominal abnormalities.
Acute renal failure.
Significant uremic complications.
High fever or other high-risk infection situation.
Temperature less than 90 degrees F (Fahrenheit).
 Severe nutritional abnormalities.
 Severe electrolyte abnormalities.
Acute blood loss causing significant abnormality.
Severe anemia.
High-risk low platelet count.
Disseminated intravascular coagulation.
Severe adverse drug or systemic toxin reaction requiring inpatient treatment.
Severe pain requiring acute inpatient management.
Severe behavioral health issues.

Inpatient monitoring needed; examples include:
Vital signs, neurologic signs, or vascular checks more frequently than every four hours.
Cardiac or respiratory monitoring beyond the scope (eg, over 24 hours) of observation care.
Pulmonary artery catheter monitoring.
Suspected compartment syndrome.
Cerebral bleeding, hydrocephalus, or vasospasm monitoring.
Increased intracranial pressure or cerebral edema monitoring.
Fetal monitoring.

Treatment requiring inpatient care; examples include:
IV fluid to replace significant ongoing losses (greater than three liters per meter squared per day).
High concentration oxygen (greater than 40%).
Frequent respiratory therapy (more frequently than every four hours) to maintain airflow rates greater than 60% of baseline.
Epidural analgesia(83).
Intravenous (IV) anticoagulation, vasoactive, or antiarrhythmic medication.
Acute thrombolytics (generally require 24 hours of observation).
Emergency procedures needed.

This patient did not have any of the Milliman Care Guidelines conditions. She had pain following the surgery but was hemodynamically stable. Her pain was controlled with analgesics. She did not have any significant physiologic or surgical complications following the procedure.  She could have been managed at an observation level of care.

According to the Milliman Care Guidelines General Admission Criteria: "General Criteria: Observation Care. Observation is not a location within the hospital, but rather a short period when the same active diagnostic and therapeutic services used during an inpatient hospitalization are provided to gather more information and assess the response of the patient. Typically it is 48-hours or less, but can be up to 72-hours in certain situations."  This patient was medically stable and needed only additional analgesic medication and intravenous hydration. She could have been safely managed at an observation level of care.

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
Admission was not medically necessary. The patient could have been managed at an observation level of care.