Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Breast ptosis.
Treatment:  Inpatient admission.

The insurer denied the inpatient admission.  The denial is upheld. 

The patient is a female, who has a history of bilateral breast augmentation with saline implants.  She requested removal of her implants and bilateral mastopexies for ptosis.  Her surgeon performed implants removals and mastopexies.

No, the inpatient admission was not medically necessary. 

According to the Milliman Care Guidelines, 24th Edition, "General Admission Criteria", admission is indicated for one or more of the following:  1) Hemodynamic instability, 2) Hypertension requiring inpatient treatment, 3)  Acute cardiac or peripheral ischemia, 4) Cardiac arrhythmias of immediate concern, 5) Severe heart failure, 6)  Respiratory abnormalities, 7) Severe airflow or ventilation abnormalities, 8) Impending or actual respiratory arrest, 9) Neurologic abnormalities, 10) New-onset severe neurologic findings, 11) Suspected acute intra-abdominal process, 12) Severe physiologic disorder, 13) Abdominal abnormalities, 14) Acute renal failure, 15) Significant uremic complications, 16) High fever or other high-risk infection situation, 17) Temperature less than 90 degrees F (32.2 degrees C) (rectal)(61), 18) Severe nutritional abnormalities, 19) Severe electrolyte abnormalities, 20) Acute blood loss causing significant abnormality, 21) Severe anemia, 22) High-risk low platelet count, 23) Disseminated intravascular coagulation, 24) Severe adverse drug or systemic toxin reaction requiring inpatient treatment, 25) Severe pain requiring acute inpatient management, 26) Severe behavioral health issues, 27) Inpatient monitoring needed; examples include:  a) Vital signs, neurologic signs, or vascular checks more frequently than every four hours, b) Cardiac or respiratory monitoring beyond the scope (e.g., over 24 hours) of observation care, c) Pulmonary artery catheter monitoring, d) Suspected compartment syndrome, e) Cerebral bleeding, hydrocephalus, or vasospasm monitoring, f) Increased intracranial pressure or cerebral edema monitoring, and g) Fetal monitoring; 28) Treatment requiring inpatient care; examples include:  a) Intravenous (IV) fluid to replace significant ongoing losses (greater than 3 liters per meter squared [L/m2] per day), b) High concentration oxygen (greater than 40%), c) Frequent respiratory therapy (more frequently than every 4 hours) to maintain airflow rates greater than 60% of baseline, d) Epidural analgesia, e) Intravenous (IV) anticoagulation, vasoactive, or antiarrhythmic medication, and f) Acute thrombolytics (generally require 24 hours of observation), and  g) Emergency procedures needed.

This patient did not have any of these conditions.  She had pain following the surgery but was hemodynamically stable.  Her pain was controlled with analgesics.  She did not have any significant physiologic or surgical complications following the procedure.  Per the Milliman Care Guidelines (MCG), 24th Edition, General Surgery or Procedure, most breast procedures can be performed as an outpatient.  This was an uncomplicated breast procedure.  She could have been managed at a lower level of care.