Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Recurrent Epistaxis

Treatment: Inpatient Hospital Stay

The insurer denied coverage for inpatient hospital stay

The denial is overturned

The patient has a number of severe medical morbidities. These included obstructive pulmonary disease, severe obesity with a body mass index = 40.8, a history of coronary artery disease, gastroesophageal reflux and diabetic polyneuropathy. She was seen in the emergency department with a history of persistent epistaxis. Her nose was packed and bleeding appeared to stop. Upon admission a computed tomography and vascular studies were obtained. These studies found:  "Heterogeneous enhancing mass in the left maxillary antrum and adjacent nasal cavity with erosion into the left orbit and left retromaxillary fat and premaxillary fat. Differential includes neoplasm, organizing hematoma, and fungal disease.  Mild right-sided proptosis. Likely obstructed secretions in the left frontal sinus and anterior ethmoid cells."

The patient underwent a surgical biopsy of the nasal mass. Her American Society of Anesthesiologist (ASA) classification was 4E (E=emergency) which is considered as:

"ASA 4: A patient with a severe systemic disease that is a constant threat to life.1"

The pathology report of the biopsy was inconclusive:
"Pathologic Diagnosis
I. Left maxillary sinus mass, biopsy:
- Sinonasal mucosa with chronic inflammation and reactive features
- Few fragments of bone
- Fibrin
- No morphologic evidence of fungal sinusitis or malignancy in this
material (see comment)
- GMS stain is negative for fungal organisms

Special stain control is appropriate"

The slides of the specimen were sent to a specialized hospital whose pathology department concurred with the interpretation of the specimen which was the original report. 

The Milliman Care Guidelines (MCG) Ambulatory Surgery Discharge and Complications: Common Complications and Conditions lists amongst the clinical indications for admission of impatient care the following any one of which would require inpatient stay of one or more days following the procedure2:  American Society of Anesthesiologists (ASA) Class III or greater - the patient had an ASA = 4E. The 'E' stands for emergency.
Symptomatic chronic lung disease (chronic obstructive pulmonary disease (COPD) - which the patient had.

Morbid obesity - this patient had a BMI = 40.8 which is classified as obese3.

The health plan did not act reasonably nor with sound medical judgment the best interest of the patient. She had three conditions which according to MCG2 guidelines any one of which would have warranted an extended stay of one or more days.

The inpatient stay is considered medically necessary for the patient as she had three severe comorbidities including chronic pulmonary disease, obesity3, and was considered an ASA 4E anesthesia risk. She was admitted and underwent surgical biopsy under general anesthesia.  She recovered and was discharge in stable condition.

On the bases that the patient fulfilled the criteria for inpatient care of 1 or more days according the MCG guidelines, the denial of inpatient stay should be reversed. 

The insurer's denial of coverage for inpatient stay is reversed. Medical Necessity is substantiated.