Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Status-post surgery (laparoscopic right orchiopexy, right inguinal hernia repair and circumcision)
Issue under review: Inpatient admission
The insurer denied the inpatient admission. 
The denial is upheld. 

The patient is a male.  He was admitted to acute inpatient level of care following laparoscopic right orchiopexy, right inguinal hernia repair, and circumcision. The child's medical history is significant for Noonan syndrome, mild supravalvular pulmonic stenosis, gastroesophageal reflux disease and hypotonia. Per the Mother, the child had an apneic episode for which she administered mouth-to-mouth and cardiac compressions. The episode lasted about a minute. The child was seen in the ER following that event and discharged home. 

The child underwent right laparoscopic orchiopexy, right inguinal hernia repair, and circumcision. Anesthesia gave the child an American Society of Anesthesiologist (ASA) two (mild systemic disease).  Postoperatively the patient was admitted to the pediatric intensive care unit (PICU) under acute inpatient level of care. The patient was on cardiac monitoring, ordered for regular diet and oral analgesia for postoperative pain. Vitals signs were normal throughout the postoperative hospital stay. 

(postoperative day # 1) The child had some bleeding from the circumcision which had occurred the previous night (noted on Progress Note) which did not require intervention. The penis was left open to air with clot formation noted. The child was observed overnight for any further bleeding. The patient was discharged (postoperative day # 2).

The acute inpatient level of care was denied as not medically necessary. This is an appeal of the previous denial. The hospital states the acute inpatient admission was medically necessary because of a previous apneic episode reported by the Mother and that given the child's underlying condition related to Noonan syndrome, the physicians appropriately determined inpatient admission was reasonable and appropriate to treat the patient's presenting symptomatology.

No, the proposed treatment, acute inpatient level of care / critical care for the postoperative care and course, was not medically necessary. The care could have been rendered at a lower level of care. 

The patient is an uncircumcised male with a right undescended testicle. The patient suffers from Noonan syndrome. Noonan syndrome is a congenital disorder marked by abnormal facies, short stature, skeletal abnormalities, bleeding problems, development delay, and cardiac problems. The severity of the illness and life expectancy is usually normal except as related to the severity of the heart defect. The child's cardiac anomaly is mild pulmonic valve stenosis which is not of severity that a cardiology clearance or work up was carried out. The reported indication for inpatient admission was the reported history of an apneic episode at home which according to the parent required chest compressions and mouth-to-mouth resuscitation. The child was seen after the event in the ER and did not require admission to the hospital. The only documented cardiac event was ten months ago when the child developed an apneic event and required chest compressions at home. He was subsequently seen at the hospital and discharged home. 

In patients undergoing surgery, bleeding risk also needs to be assessed. A study by Nugent (2018) evaluated 31 studies of bleeding disorders which included patients with Noonan Syndrome. Of these patients, 43% had reported bleeding, 26% had no reported bleeding and no bleed data was reported for 31%. The authors concluded clinical evaluations should be performed at diagnosis, after diagnosis, before any surgery is undertaken, and if patients become symptomatic. In this case, there was no evaluation for a bleeding disorder and the bleeding that the patient experienced at the circumcision site was self-limited and not severe enough that there was a record of a follow-up blood count. The child experienced bleeding from the circumcision the night of surgery which did not require intervention as the child formed clot at the bleeding site most consistent with usual postoperative complications of circumcision rather than pathological in nature. 

Laparoscopic orchiopexy with or without inguinal hernia repair and circumcision are outpatient surgical procedures. As a result of the previous life-threatening event, it was deemed that the child should be monitored overnight. Postoperative orders included regular diet and non-narcotic oral analgesia. Postoperative apnea monitoring does not require the intensive acre unit (ICU) level of care and does not require acute inpatient level of care. The patient's preoperative condition did not require an acute inpatient level of care for monitoring. The self-limited bleeding from the circumcision did not warrant the additional overnight stay.