Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cervical cancer.
Treatment: Surgery services (procedure code 62350) and inpatient stay.

The insurer denied coverage for surgery services (procedure code 62350) and inpatient stay.  The denial is overturned.

This is the case of a female with a history of cervical cancer and right femur fibrous dysplasia, hypertension, and anxiety. She underwent intrathecal pump (ITP) placement to treat her pain. Post operatively, she was transferred to the Post Anesthesia Care Unit (PACU). The plan was to start intravenous (IV) patient-controlled analgesia (PCA) Dilaudid and settings were placed with ITP. The patient was seen in the PACU and met discharge criteria to be sent to the inpatient unit.

Based upon the records, the surgical service of ITP placement was appropriate as noted by the hospital. The patient had failed conservative treatment with pain management having had multiple pain treatments without success. In addition, as noted by the hospital, bisphosphonate infusions were tried in the past without success as well as other narcotic and non-narcotic regimens. The hospital also noted that the pain was not due to psychological disorder but rather to a structural disorder, and, therefore, a psychologist was not warranted. Finally, as noted by the hospital she met criteria for ITP, as she failed conservative measure, and she was dependent on pain medication to function with side effects and failed to respond to multiple surgeries. Therefore, the procedure was indicated. 

In reference to the inpatient admission, it was indicated given that the patient had urinary retention following administration of the pain medication via ITP and also developed postural headaches requiring a blood patch. It is true that this procedure is normally an ambulatory procedure. However, in this case, given the severity of the urinary retention requiring multiple straight catheterizations on a daily basis until the ITP dosing was changed, and then the medication could be changed, as well as the need for the blood patch, the hospital admission was warranted as well as the continued inpatient care. Despite being treated with straight catheterization and not having an indwelling Foley catheter, the patient did develop a urinary tract infection (UTI) requiring antibiotics and thus delaying the conversion of the ITP to Morphine and to the placement of the blood patch.

The patient met criteria as noted by Milliman Care Guideline (MCG) Health - Ambulatory care 26th edition. Intrathecal pump implantation. (1) Although it is usually performed as an ambulatory procedure, given the fact that the patient suffered significant urinary retention and positional headaches, following the procedure complicated by a UTI, inpatient admission and continued inpatient status was warranted. 

In addition, the patient met criteria according to MCG Health Inpatient and surgical care 26th edition Ambulatory surgery discharge and complications: common complications and conditions (2). Based upon these criteria she did require an acute care admission, as she did have a postop event in the form of acute urinary retention requiring multiple straight catheterizations due to the ITP medication dosing which needed to be titrated.

Finally, patient met MCG General Recovery care 26th edition Ambulatory surgery exception criteria (3). The patient did warrant inpatient status as she did develop, with initiation of the ITP pain medication, significant urinary retention requiring multiple straight catheterizations on a daily basis as well as positional headaches requiring a blood patch. 

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 surgery services (procedure code 62350) and inpatient stay is overturned. Medical Necessity is substantiated.