Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Adenocarcinoma of the Colon
Treatment: Inpatient Hospital
The health plan denied two dates of service during this inpatient stay. 
The health plan's determination is upheld.

The patient is a man who was admitted with the diagnosis of adenocarcinoma of the colon. He has the past surgical history of a loop colostomy performed. He has also been treated with neoadjuvant chemotherapy (FOLFOX).

The patient was admitted to the hospital and underwent an exploratory laparotomy with hemicolectomy, small bowel resection, colostomy reversal, and application of a negative pressure wound vacuum-assisted closure (VAC).

The post-operative progress note documents normal vital signs. He was on a liquid diet. Pain management was with epidural narcotic medication in addition to non-narcotic adjunct pain medications. The abdomen was mild to moderately distended, but non tender. The patient was passing flatus.

The epidural catheter inadvertently came out. He was treated for post-surgical pain with intravenous (IV) narcotics. The patient also had nausea and vomiting. The patient was still being treated with the negative pressure wound vacuum for the abdominal incision. He was without fever and was tolerating liquids. The surgical drain was putting out relatively high volumes of serosanguinous fluid. The following day the patient was without pain, nausea or vomiting. He was reported to be passing flatus and tolerating a clear liquid diet. The existing surgical drain was to be removed the following day. Oral intake was reported to be improved. The patient was discharged from the hospital.

The records include MCG 21st edition-Bowel Surgery: Colectomy, Partial with or without ostomy. These guidelines state that the goal length of stay is 4 days post-operative. Extended stay may be needed for severe preoperative disease, post-operative complications, continued ileus, or multiple injuries. A moderate extended stay is 4-7 days, and a prolonged extended stay is more than 7 days per these guidelines.
At issue is the medical necessity of the inpatient stay. 

The health plan's determination of medical necessity is upheld, in whole.

No, continued inpatient admission was not medically necessary and was consistent with the submitted MCG. The patient was progressing normally post-surgery. He was tolerating a diet, had normal vital signs, and had return of bowel function. Continued inpatient care was not required on the denied dates of service.

This patient is a man with colon cancer. He underwent surgical resection of the colon cancer. Per the health plan the patient no longer required inpatient care on the denied dates of service. His initial post-surgical recovery was uncomplicated with normal progression of diet and return of bowel function. The records support that the patient was clinically stable and could have been discharged from the hospital. The patient was tolerating a diet, he had stable vital signs and pain control could be achieved with oral medications. The progress notes and nursing records support that the patient was without pain, nausea or vomiting. He was reported to be passing flatus and tolerating a clear liquid diet.

Discharge would have been consistent with the submitted MCG. While extended stay may be needed for severe preoperative disease, post-operative complications, continued ileus, or multiple injuries, in this case none of these conditions existed to mandate continued inpatient stay.