Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Paget's disease
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

This patient is an adult male. He presented to the hospital with the diagnosis of extramammary Paget's disease in the left groin. His comorbid health conditions included hypertension, hyperlipidemia, chronic kidney disease, pre-diabetes, and benign prostatic hypertrophy. The patient underwent excision of the left groin/lower extremity Paget's disease with complex wound closure. The operative note describes excision of the involved skin and subcutaneous tissues by the surgical oncology service followed by wound closure performed by the plastic surgery team. There were no intra-operative complications, and the patient was clinically stable throughout the operation. Vital signs were normal following surgery. The submitted nursing, surgical, ED (emergency department) and anesthetic records document hemodynamic stability during the perioperative period. The patient was able to tolerate a diet following surgery. Pain medications were converted to oral medications. He was discharged from the hospital. The health plan denial letter states that the care and treatment provided did not require inpatient admission. This letter states that Observation services are considered medically necessary for an individual who requires the following in any location within a hospital: short term monitoring that is not expected to exceed 24 hours but would generally be no longer than 48 hours, etc. Per this letter, there is no documentation of an adverse change in clinical status, intensity of services or new condition supporting change to an inpatient level of care after the observation period. The medical records document that the severity of the patient's clinical condition, combined with the scope and intensity of diagnostic and therapeutic services rendered do not exceed the health plan utilization review guidelines. This denial is being appealed.

The Inpatient Hospital Admission was not medically necessary.

The care and treatment could have been reasonably rendered with a lower level of care. In this case there was not documentation of surgical complications, comorbid health problem, or other clinical condition that required inpatient care. The patient underwent a surgical procedure and experienced no perioperative complications. He was able to tolerate a diet following surgery and oral pain medications. The patient was stable for discharge from the hospital on the first post-surgical day.

There is no compelling clinical reason why this patient could not have safely and appropriately received evaluation and treatment at the observation level of care with subsequent transition to outpatient care, rather than admission to inpatient level of care. The care provided could have appropriately been rendered with an observation level of care. This patient presented to the hospital with the diagnosis of extramammary Paget's disease of the left groin. The patient underwent surgery to excise this lesion. The period of monitoring was otherwise uncomplicated. He was able to be discharged following an initial period of recovery on the first post-surgical day. The records support that inpatient care and treatment was not medically necessary. An observational designation with monitoring would have satisfied the needs of this patient. Provision of IV (intravenous) fluid, pain medications, antiemetics, and surgery could have been appropriately provided in the observational setting. This level of care would have provided for regular clinical assessment, follow up monitoring, surgical excision of the left groin Paget's disease, and provision of the prescribed IV (intravenous) medications and fluid as he was transitioned to oral medications. The observational 
level of care would have also allowed for overnight observation.