Appeal type: Medical necessity
Decision: Overturned

Diagnosis: High-grade spindle cell sarcoma.
Treatment: Continued hospital admission.
The insurer denied coverage for continued hospital admission.
The denial is overturned.

The patient has a history of right high-grade spindle cell sarcoma and multiple prior resections. He has chronic right foot drop and numbness over his distal foot and is now presented for scheduled revision with wide resection of the lesion including likely necessitating sacrifice of the common peroneal nerve and proximal fibular resection to maintain negative tumor margins. He underwent wide excision of the tumor with resection of the sciatic nerve and proximal fibula with free flap and microvascular reconstruction. This was a combined procedure between oncologic surgery and plastic surgery and took approximately 11.5 hours of surgical time. He was admitted to the Post Anesthesia Care Unit (PACU) post-surgery. He was continued on epidural medication as well as Cefazolin for an antibiotic.

Based on the records, the continued hospital admission was appropriate. This patient required epidural patient-controlled analgesia (PCA) for many days and then intravenous (IV) PCA for pain control. He also required IV Cefazolin and then required IV Zosyn and Vancomycin. The patient had a major resection of sarcoma including bone and required to be kept in the left lateral position for many of those days. He required continued inpatient care as he needed to have his wounds evaluated to prevent infection. He did develop a wound infection with Pseudomonas, for which he had to be treated with Vancomycin and Zosyn. 

The patient met the criteria according to Milliman Care Guideline (MCG) General Recovery care 26th edition Musculoskeletal surgery or procedure GRG: SG-MS (ISC GRG). The patient required continued inpatient care as he did not meet the criteria for discharge earlier than when he was discharged. He required continued inpatient care as his operative site was not acceptable; his pain was not controlled except by epidural PCA and then IV PCA. His activity level was not acceptable as he was maintained on bed rest and then only began to be allowed to dangle his leg. He required a split-thickness skin graft (STSG) and then he was required to have a wound aspiration followed by antibiotics. He, therefore, required continued inpatient hospital admission. 

The patient also met the criteria according to MCG Health General Recovery Guidelines 26th Edition General Surgery or Procedure GRG: SG-GS (ISC GRG). The patient required epidural PCA as well as IV PCA and also required IV antibiotics because of his wound. His activity level was not acceptable as he was maintained on bed rest and required physical therapy. To carve out his hospital stay and say his continued stay should be denied is unreasonable. In this case, he required after a major sarcoma resection to be monitored closely for wound infection and pain control. 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient. 

The insurer's denial of coverage for continued hospital admission is overturned. Medical Necessity is substantiated.