Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Parathyroid adenoma status post parathyroidectomy. 
Treatment: Inpatient admission. 
The insurer denied coverage for Inpatient admission. 
The denial is upheld. 

According to the patient's medical record, this is an adult with asthma, chronic obstructive pulmonary disease (COPD), diabetes, hyperlipidemia, hypertension (HTN), and schizoaffective disorder who presented for elective parathyroidectomy four gland explorations. Pre-operative ultrasound indicated a 0.9 x 0.8 x 0.7 cm (centimeter) hyperechoic nodule inferior to the left thyroid lobe representing a parathyroid gland. The impression was a parathyroid adenoma lesion on the left anterolateral trachea. 

The patient underwent an uneventful 4 gland exploration. As per the operative note, a 640 milligram (mg) left inferior parathyroid adenoma and a 120 mg right inferior parathyroid adenoma were resected; bilateral recurrent laryngeal nerve was not specifically identified. Baseline parathyroid hormone (PTH) decreased from 173 to 9.29 approximately 30 minutes following exploration, confirming a successful biochemical response. 

Post post-operative note indicated there was no numbness or tingling in the hands, feet, or lips. The pain was controlled. The wound was soft and flat with the dressing intact. 

Postoperatively the patient did well with surgery and was transferred to the floor. The postoperative PTH was 9.29, and calcium supplementation per protocol was started. The calcium levels trended and remained stable. The patient was otherwise tolerating a regular diet, voiding, and ambulating and was discharged to home the next day. 

The hospital is appealing and noted in an appeal letter that this is a patient with hypertension (HTN), diabetes, asthma, chronic obstructive pulmonary disease (COPD), schizoaffective disorder, and primary hyperparathyroidism who presented for surgical management. The patient underwent parathyroidectomy and four gland exploration. Intravenous (IV) fluids, Tylenol, Oxycodone, and home medications were administered. Calcium citrate was initiated, and the patient was discharged the next day. This patient met Milliman Care Guidelines (MCG) criteria for inpatient care under SG-HNS Head and Neck Surgery or Procedure. 

Based on the information provided, the inpatient admission was not medically necessary as the patient could have been managed with a 23-hour observation which would have included appropriate post-operative monitoring and care. According to Milliman Care Guidelines (MCG) Health Inpatient and Surgical Care 27th Edition Parathyroidectomy ORG: S-930 (ISC) the operative status goal is ambulatory. Extended Stay as defined by Minimal (a few hours to 1 day), Brief (1 to 3 days), Moderate (4 to 7 days), and Prolonged (more than 7 days) is indicated for select situations. Inpatient stay may be needed for: Failure to achieve discharge status criteria; Severe renal impairment; Preoperative diagnosis of secondary hyperparathyroidism due to renal disease; Diagnosis of parathyroid malignancy; Preoperative hypercalcemic crisis; Increased risk for bleeding; Postoperative hypocalcemia, Removal of more than one parathyroid gland; Complications of procedure; Care for active comorbidities. 

Given the above the patient did not warrant inpatient status as the patient should have been managed in an ambulatory setting/observation setting. It was not a complex surgical situation, and the patient was not a high anesthetic risk and had an uneventful total parathyroidectomy. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for Inpatient Admission is not substantiated.