Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hilar Lung Mass, Emphysema
Treatment: inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is a male with a medical history of hypertension, hyperlipidemia, history of cerebrovascular accident in 2008 with residual right sided facial drooping, glaucoma, cataracts, alcohol use, history of mycobacterium avium complex (MAC) infection, and emphysema who was sent in from the pulmonary clinic for an expedited malignancy evaluation for a right middle lobe lung mass and hypertension. Although his blood pressure was elevated, it was attributed to pain. His chronic superficial femoral artery occlusion was recommended for outpatient follow-up with the vascular surgeon. The patient was hemodynamically stable for the entire hospitalization without cardiac arrhythmias/uncontrolled hypertension/peripheral ischemia. He never required oxygen supplementation or other ventilatory support, and he was deemed appropriate to have further work-up/biopsy on the lung mass as an outpatient.

At issue is the medical necessity for an inpatient hospital admission.
I uphold, in whole, the health plan's determination of medical necessity.

The requested health service/treatment of Inpatient Hospital Admission was not medically necessary for this patient.

Based upon the severity of illness and intensity of required therapy, the inpatient level of care was not medically necessary. This patient with a history of hypertension, hyperlipidemia, history of cerebrovascular accident in 2008 with residual right sided facial drooping, glaucoma, cataracts, alcohol use, history of mycobacterium avium complex (MAC) infection, and emphysema was sent in from the pulmonary clinic for an expedited malignancy evaluation for a right middle lobe lung mass and hypertension. As per the clinical documentation on admission, the patient was afebrile and hemodynamically stable without cardiac arrhythmias/peripheral ischemia. He had an oxygen saturation greater than (>) 90 percent (%) on room air, was not in any respiratory distress, did not require invasive or non-invasive ventilator support, did not have any severe electrolyte abnormalities, and did not have severe anemia or thrombocytopenia. In addition, there was no documentation that the patient was going to start a high-risk chemotherapy that may cause toxicity or complications, was not at high risk for thrombocytopenia/severe anemia/neutropenia, did not have a high risk of infection, did not have documented hyperviscosity, did not have a recurrent malignant effusion, and was not noted have neurologic or gastrointestinal complications requiring an inpatient level of care.

Although his blood pressure was elevated, it was attributed to pain. Also, he was found to have a chronic superficial femoral artery occlusion without limb symptoms and was recommended for outpatient follow-up with the vascular surgeon. The attending physician noted that the patient would have a bronchoscopy/biopsy of the lung mass the following week as an outpatient. Based on the clinical information provided, there was no documentation indicating the patient required care at the inpatient level of care and could have had subsequent outpatient work-up of the left femoral artery occlusion and lung mass. Therefore, the inpatient level of care was not appropriate, and treatment could have been rendered at a lower level of care at an alternate level of care.