Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Invasive Ductal Carcinoma
Treatment: Inpatient Admission
The insurer denied coverage for inpatient admission
The denial is upheld.

According to the patient's medical chart, this is an adult female with a history of invasive ductal carcinoma. She presented to the hospital for a scheduled left mastectomy, with sentinel node biopsy and possible axillary dissection. She noted a left breast mass more than a year ago. Left breast sonogram was unremarkable. Bilateral mammogram showed no mammographic evidence for malignancy. Bilateral breast sonogram showed a left 2 o'clock nodule, correlating with a palpable finding. This was not identified on prior but has probably benign appearance. The patient stated the mass increased in size. And the patient underwent fine needle aspiration (FNA) with pathology revealing atypical cells. The patient did not follow up until now. She had a biopsy which showed invasive moderately differentiated carcinoma and she underwent neoadjuvant chemotherapy and returned now for surgical planning. The plan was left total mastectomy with sentinel lymph node (SLN) biopsy and probably axillary dissection.

She underwent left total mastectomy with axillary lymphadenectomy. Surgery was uneventful. Pathology revealed invasive and in situ ductal carcinoma of the left breast with metastatic ductal carcinoma in one out of 12 lymph nodes. 
Based upon the information provided, the acute inpatient admission is not approved as it was not medically necessary for in-patient care but rather outpatient care or at most observation status, as this procedure is an ambulatory procedure as noted below. The patient underwent an uneventful mastectomy and lymphadenectomy, and this could have been done under an observation status and not as an acute inpatient admission. The patient was sent home, and this should have been done as a 23-hour observation. Therefore, the inpatient admission was not necessary. 

In addition, according to Milliman Care Guidelines (MCG) health Inpatient and surgical care 26th edition Ambulatory surgery discharge and complications: common complications and conditions (CCC)Surgery or procedure performed on ambulatory basis may require inpatient stay for 1 or more of the following:  Inpatient care needed for clinically significant preoperative disease or condition; Complex surgical approach or situation anticipated; Procedure is not low risk and patient at high anesthetic risk; Presence of drug-related risk; Inadequate outpatient care situation; Postoperative event, condition, or finding that warrants inpatient stay. Based upon these criteria she did not require an acute care admission and only observation as she did not have an acute medical condition preoperatively or post operatively that required inpatient status. 

Finally, MCG General recovery care 26th edition Ambulatory surgery exception criteria notes that potentially ambulatory procedure or surgery warrants inpatient care due to 1 or more of the following: Inpatient care needed for clinically significant preoperative disease or condition; Complex surgical approach or situation anticipated; Procedure is not low risk and patient at high anesthetic risk; Presence of drug-related risk; Inadequate outpatient care situation; Postoperative event, condition, or finding that warrants inpatient stay. Given the above, the patient did not warrant inpatient status as there was no concern for a clinically significant preop disease. Thus, inpatient admission was not warranted.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient admission is not substantiated.