Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal/Hernia
Treatment: Inpatient Hospital
The health plan denied the inpatient stay as not medically necessary. 
The health plan's determination is overturned.

This patient is a male with a past medical history of schizoaffective disorder, cocaine abuse, deep vein thrombosis, current smoker who presented for an elective left inguinal hernia repair under general anesthesia with endotracheal intubation. While the surgery itself was completed uneventfully, intraoperatively, the patient's blood oxygen saturation was about 88% and he required 60-70% fraction of inspired oxygen (FiO2) during the case. Pulmonary pressures were elevated to 35-38 millimeters of mercury (mmHg). After extubation, the oxygen saturations dropped to 70%. Due to the patient's thick, frothy respiratory secretions, diuretics (Lasix) were given, and the patient was also treated with steroids and Albuterol to combat bronchospasm. In the post-anesthesia care unit (PACU), the patient was tachycardic (heart rate 100-110 beats per min) and was treated with 4 liters of oxygen via face mask. Arterial blood gas without oxygen supplementation showed a partial pressure of oxygen (PaO2) of 43 mmHg. A chest computed tomography (CT) scan did not show pulmonary embolism, but did show diffuse pulmonary edema, pulmonary hypertension, and moderate to severe emphysema. A transthoracic echocardiogram (TTE) showed moderate to severe mitral valvular regurgitation, fluid overload, and pulmonary hypertension. Due to these findings, he was admitted to the telemetry unit and treated with further diuretics and nebulizers. As the patient's oxygenation improved and requirement for supplemental oxygen was weaned, he was discharged.

The key issue is whether inpatient care was medically necessary for this patient.

For the reasons stated above, I overturn, in whole the health plan's determination of medical necessity.

Inpatient stay with monitoring on a telemetry unit was medically necessary for this patient. The patient was diagnosed with acute hypoxic respiratory failure due to pulmonary edema after inguinal hernia repair. Inpatient telemetry monitoring was necessary to adequately monitor this patient and to gauge response to pharmacologic treatments (e.g., diuretics). National and international guidelines emphasize the need for continuous physiological monitoring including pulse oximetry, blood pressure measurement and electrocardiography in patients with post-operative hypoxemia. Mismanagement of post-operative complications through inadequate monitoring can lead to prolonged hospital stay, unplanned Intensive Care Unit (ICU) admissions, and 30-day post-operative mortality.

As noted in the medical record and in the above summary, the patient's heart rate and breathing rate were not normal after extubation or in PACU. Notes in the medical record by the anesthesiologist and the internal medicine (hospitalist) physicians clearly indicate the need for more intensive monitoring (particularly of oxygenation) after surgery that extended beyond standard ambulatory care. Given the extensive pulmonary edema present in this patient (as noted by CT scan and TTE) resulting in low oxygenation after extubation and in PACU (PaO2 of 43 on room air arterial blood gas), there is no reasonable way that this patient could have been safely treated at a lower level of care. While pharmacologic diuresis did improve the patient's oxygenation, intensive monitoring at an inpatient level of care was necessary to gauge the patient's response to this treatment.