Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Invasive adenocarcinoma of the esophagus. 
Treatment: Inpatient Hospital Stay. 

The insurer denied the Inpatient Stay. 
The determination is overturned. 


The patient has a history of sarcoidosis and invasive adenocarcinoma of the esophagus who was admitted following an esophagoscopy and robotic assisted distal 2/3 Ivor Lewis esophagectomy (with thoracotomy) and feeding jejunostomy insertion. A right pleural effusion was identified which required a chest tube. The patient had complications of an anastomotic leak and small hydropneumothorax which required placement of a chest tube and removal. The patient was treated with nebulized Atrovent and Xopenex treatments every 6 hours. She received intravenous (IV) Zosyn. The pain was managed initially with IV Fentanyl, IV Dilaudid, and IV Toradol. She was then transitioned to oral pain medications. The patient developed diarrhea and the stool was found to be Clostridium difficile (C diff) positive and the patient was started on vancomycin 125 milligrams (mg) every 6 hours. The patient's diarrhea persisted and the patient remained nothing by mouth (NPO) with small sips of water. The vancomycin was adjusted. IV Protonix for GI prophylaxis was continued and Lactobacillus was initiated. The patient required continuing aggressive pulmonary toilet and titration of pain medications. On postoperative day (POD) 15 , feedings continued via her jejunostomy (J)-tube and she remained NPO with sips of water. The watery diarrhea persisted and the patient complained of cramping. The vancomycin was changed to liquid. An aggresive pulmonary toilet continued. The diarrhea persisted. Nutrition was consulted. Jevity was started. Her watery stools showed some improvement and she was taking small sips of water. The blood work remained stable. The patient was afebrile and her vital signs remained stable. The patient was discharged to home with home health care arranged. At issue is the medical necessity of an inpatient stay. 

The inpatient stay was medically necessary. 

This patient had several complications during her hospitalization. Minimally invasive esophagectomy has been developed to reduce the surgical trauma, resulting in lower mortality and incidence of complications when compared with open esophagectomy, and it is now accepted as a regular treatment modality for patients with esophageal carcinoma. The overall incidence of postoperative complications varies widely between 20 and 80 percent and includes systemic complications (eg, pneumonia, myocardial infarction) and complications specific to the surgical procedure (eg, anastomotic leaks, recurrent laryngeal nerve injury.). Pulmonary complications are the most common postoperative complications, occurring in 16 to 67 percent of patients, but anastomotic leak (AL) is the most dreaded, occurring in 0 to 40 percent of patients - anastomotic leak is a serious complication of the Ivor Lewis operation and is associated with increased mortality. Successful treatment of AL requires an individual and multidisciplinary approach. The approach to anastomotic leak has been to control drainage, nil per oral (NPO), and antibiotic therapy. In the setting of mediastinitis or empyema, surgical debridement is utilized. This patient was made NPO and was treated with antibiotics. She developed diarrhea and her stool was C Diff positive. She was appropriately treated with vancomycin. The formula for jejunostomy feeds was changed and she improved. 
 
The Milliman Care Guidelines (MCG) Health Inpatient & Surgical Care 23rd Edition indicates that the Goal length of stay for esophagectomy is 7 days postoperative. As noted, extended stay (prolonged being more than 7 days beyond goal length of stay - as in this patient), may be needed for: respiratory complications (patient required aggressive pulmonary toilet and required placement of a chest tube for hydropneumothorax) and anastomotic leak. In addition to the complications associated directly with the surgery (hydropneumothorax and anastomotic leak), the patient developed diarrhea with C Diff positive stools and required close clinical monitoring for fluid and electrolyte balance. The patient was also having cramping. Clostridium difficile (C. diff) is the most common causative agent of antibiotic-associated diarrhea and colitis. Clostridium difficile infection causes a spectrum of disease, ranging from occasional diarrhea to colitis, toxic megacolon, and potentially death. The patient initially was not improving but subsequently did improve with regards to her diarrhea/C diff. This patient had an esophagectomy which was complicated by an anastomotic leak. The patient also developed diarrhea with stool positive for C Diff. Per the above criteria and MCG criteria, the hospital admission was medically necessary.