Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Inpatient Hospital Care. 
The insurer denied the inpatient stay. 
The denial is overturned.

The patient is a male who presented for a scheduled pancreaticoduodenectomy with portal vein resection for the diagnosis of a mass of the head of the pancreas. Comorbid health conditions included hypertension, coronary artery disease, myocardial infarction with two stents, aortic and mitral valve insufficiency. This 5-hour procedure was performed with an estimated blood loss of 400-cubic centimeters (cc). The following day the patient was receiving pain medications via epidural in addition to intravenous (IV) narcotics. The hemoglobin value was 8.8 grams per deciliter (g/dl), down from 11.1 g/dl immediately post-procedure. He had a nasogastric tube in place, a Foley catheter and a surgical drain in the abdomen.

The following day, the hemoglobin value had decreased further to 7.7 g/dl. He had urinary retention that required reinsertion of the Foley catheter the next day. He was receiving IV fluid, parenteral analgesia, and was nothing by mouth (NPO) status. The drain amylase value was low and the epidural catheter and Jackson-Pratt (JP) drain were removed. He was started on oral narcotic medications for pain control.

The following day, the hemoglobin value was 7.4 g/dl. The Foley catheter was still in place for urinary drainage. The next day, the patient manifested orthostatic hypotension with a systolic blood pressure reported to be in the 70's millimeters of mercury (mmHg) systolic. The patient was monitored with telemetry that documented several short runs of supraventricular tachycardia. The Foley catheter was successfully removed and the patient was able to void. The next day the patient was able to be advanced to a regular diet. He was discharged from the inpatient setting.

Based on the submitted clinical documentation, an inpatient level of care was medically necessary. This patient was admitted to the hospital with the diagnosis of a pancreatic mass (cancer). He underwent an open abdominal operation and resection of the pancreas and duodenum with cholecystoenterostomy, duodenojejunostomy and pancreaticojejunostomy. The operation also included a segmental resection of the portal vein with vascular reconstruction. The early post-procedure course was notable for a urinary retention that necessitated reinsertion of the urinary catheter. He also had an episode of hypotension that was evaluated with telemetry monitoring. This patient has a significant past cardiac history and continued inpatient care was appropriate and consistent with standard guidelines including the Milliman Care Guidelines (MCG) for pancreatectomy that state that the anticipated inpatient admission is 5-7 days. In this case, evaluation of post-surgical anemia, orthostatic hypotension and ventricular arrhythmia, urinary retention, care of comorbidities, and appropriate advancement of diet all warranted and supported an inpatient level of care following major abdominal surgery. The submitted medical records support that this patient's care and evaluation could not have reasonably been performed with a lower level of care for the dates under review.