Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gynecological-atypical hyperplasia
Treatment: Inpatient hospital stay
The health plan denied the continued inpatient stay as not medically necessary. 
The reviewer has overturned in whole the health plan's determination of medical necessity.

The patient has a history of right breast invasive ductal carcinoma, status/post (s/p) quadrantectomy, lymph node dissection, chemotherapy and radiation therapy, hypertension (HTN), sick sinus syndrome(SSS) status/post (s/p) permanent pacemaker(PPM), non-ischemic cardiomyopathy s/p PPM upgrade to cardiac resynchronization therapy defibrillator(CRT-D) with improved LV function, who presented with atypical hyperplasia and plans for laparoscopy. This operation was converted to an exploratory laparotomy, extensive lysis of adhesions, total abdominal hysterectomy with bilateral salpingo-oophorectomy, appendectomy, and small bowel resection. The patient was admitted to the hospital post-operatively. The patient was noted to be stable with pain controlled by a hydromorphone patient controlled analgesia (PCA). Sips of water were tolerated but the patient had not ambulated yet or had evidence of bowel function. Blood pressure was 96/62 and urine output was considered low at 455 cubic centimeter total at that point, thus a fluid bolus was provided. Cardiology consultation was obtained. Recommendations were to resume home carvedilol once systolic blood pressures (SBPs) were consistently greater than(>) 105 millimeters of mercury (mmHg). The pain remained controlled with a fentanyl PCA. Regular diet was tolerated, but there was still no evidence of bowel function. Treatment plan was to transition from PCA to oral analgesia when tolerating adequate oral intake. Additionally, plans were to remove the Foley catheter for a voiding trial. The patient had ambulated and voided spontaneously, and pain was controlled with an oral analgesic regimen. However, there was still no evidence of bowel function. The following day the patient was ambulating well and was documented to have return of bowel function with flatus and stool. The patient was deemed medically stable for discharge.

Based on the clinical documentation provided, evidence based literature, and standards of care, continued acute inpatient level of care was indicated as medically necessary for the entire admission.
The patient presented for a planned laparoscopic operation which was converted to an exploratory laparotomy, extensive lysis of adhesions, total abdominal hysterectomy with bilateral salpingo-oophorectomy, appendectomy, and small bowel resection. Post-operatively, the patient required a PCA for analgesia beyond the observation care time. Moreover, the patient did not have return of bowel function, suggestive of a persistent post-operative ileus, well beyond the observation time period.
Vather et al. note prolonged post-operative ileus (PPOI) occurs in up to 25% of patients following major elective abdominal surgery. It is associated with a higher risk of developing post-operative complications, prolongs hospital stay and confers a significant financial load on health-care institutions."[1] In this particular situation, the patient had an expected post-operative ileus following an exploratory laparotomy and small bowel resection which extended beyond the observation time frame. Moreover, clinical indications for admission to inpatient care were met. The patient had evidence of a persistent ileus (lack of flatus or bowel movements) as well as severe pain requiring acute inpatient management evidenced by intravenous opioid treatment required beyond the observation time period as adequate oral intake had not yet been attained.[2][3][4]