Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Metastatic Anal Melanoma
 
Treatment: Pre-Planned Hospital Admission

The insurer denied the Pre-Planned Hospital Admission. The denial was reversed.  
This is a female patient with a medical history of immunotherapy related colitis, rheumatoid arthritis and anal melanoma with liver metathesis. The patient underwent a scheduled hepatic embolization and a liver biopsy. She was admitted to the hospital post-procedure for further monitoring. The patient experience two febrile episodes with tachycardia within the first 24 hours post procedure. She was received intravenous (IV) fluid bolus and IV Zosyn; her lactic acid was elevated to 2.4. The sarcoma service consulted on the patient. It was reported that the febrile episodes were thought to be inflammatory rather than infectious. The patient was medically stabilized and discharged home with instructions for outpatient follow up.
According to MCG health General Recovery Guidelines 23rd edition General Surgery or Procedure GRG: SG-GS (ISC GRG), Operative Status Criteria is ambulatory for many procedures. Examples include: Endoscopic procedures; Embolization procedures; Most biopsy procedures; Many elective operations; including Stoma  repair, Fistula repair, Lymph node surgery; Hernia repairs in the absence of ALL of the following: Emergency procedure (e.g. strangulated hernia), Severe co morbid disease (e.g., severe infection), Complex approach (e.g., morbid obesity, large chronic incarceration); Hemorrhoid or rectal surgery; Most breast procedures; Percutaneous and dilation procedures; Liver biopsy.  Although this patient did have an embolization, and this could have been done as an observation status as noted by the insurer, the patient was monitored and clearly did require the inpatient stay. In this case she could not have been managed as an outpatient without acute inpatient hospitalization. She did need acute care services for pain control as well as continuous IV fluids as well as IV antibiotic given the concern for an infectious cause with a temperature greater than 38 degrees. She therefore could not have been observed with a 23 hour observation period.

Furthermore, according to MCG health General Recovery Care 23rd Edition General Admission Criteria GRG: CG-GAC (ISC GRG) admission is indicated for 1 or more of the following: Hemodynamic instability; Hypertension requiring inpatient treatment; Acute cardiac or peripheral ischemia; Cardiac arrhythmias of immediate concern; Severe heart failure; Respiratory abnormalities; Severe airflow or ventilation abnormalities; Impending or actual respiratory arrest; Neurologic abnormalities; New-onset severe neurologic findings; Suspected acute intra-abdominal process; Severe physiologic disorder; Abdominal abnormalities; Acute renal failure; Significant uremic complications; High fever or other high-risk infection situation; Temperature less than 95 degrees F (35 degrees C) (rectal); Severe nutritional abnormalities; Severe electrolyte abnormalities; Acute blood loss causing significant abnormality; Severe anemia; High-risk low platelet count; Disseminated intravascular coagulation; Severe adverse drug or systemic toxin reaction requiring inpatient treatment; Severe pain requiring acute inpatient management; Severe malnutrition; Severe behavioral health issues; Inpatient monitoring needed; Treatment requiring inpatient care; Emergency procedures needed. This patient did have the indications for admission based upon the above criteria.

Finally according to MCG health Inpatient and surgical care 23rd edition Ambulatory surgery discharge and complications: common complications and conditions CCC:CCC- 044 (ISC) Surgery or procedure performed on ambulatory basis may require inpatient stay for 1 or more of the following: Preoperative situation, condition, or finding that warrants inpatient stay; or postop perspective that the patient required inpatient stay rather than just observation status. Thus, this patient did require acute admission.

Therefore, based upon the clinical information provided the health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient in denying this admission as this patient could not have been managed in an observation status. 

Based on the above, the medical necessity for the pre-planned hospital admission for radiation therapy is substantiated.  The insurer's denial is reversed.