Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Obstructive Sleep Apnea. 
Treatment: Inpatient admission. 
The insurer denied coverage for inpatient admission. 
The denial is upheld. 

This patient is a child whose birth was uncomplicated. The patient was seen in the clinic and found to have symptoms consistent with obstructive sleep apnea (OSA). The patient's tonsils were two to three times in size with 100% adenoid obstruction. The patient had been noted to be having periods of apnea, snoring, congestion, and daytime mouth breathing. Flonase was tried and was of no help. The patient was brought in for a tonsillectomy with adenoidectomy (T&A). The patient's apnea-hypopnea index (AHI) was abnormal at 26. The procedure was uneventful and the patient was stable in the Pediatric Intensive Care Unit (PICU). The patient had a pulse rate of 112 and temperature of 99.8 in the recovery room. The surgeon stated in a post-op order that the patient should be observed in PICU overnight for post operative airway monitoring. It appears that the patient was admitted with a known nadir of 26 and an oxygen (O2) sat of 74% and the supporting justification (in retrospect) was a tachycardia (112, 107) and a temperature (99.8, 99.8). The child was discharged on post op day one. The issue here is justification for admission. 

The inpatient admission was not considered medically necessary for this patient. The tachycardia (107 and 112) and temperature elevation (99.8) are not all that impressive but certainly with the patient's history consistent with sleep apnea and the nadir of 26 coupled with a diagnosis of sleep apnea, overnight PICU observation was indicated. 

"Interestingly, all children requiring reintubation did so within 2 to 3 hours after the procedures were completed. This would suggest that clinical judgments could be based on the immediate postoperative course in the recovery room. However, many other perioperative respiratory complications (PRCs) requiring at least oxygen supplementation did occur over the first full 24 hours postoperatively. It is difficult to predict if the intervention provided at the time of PRCs prevented other worse outcomes or more serious respiratory difficulties. Future prospective studies should examine the time course of respiratory events in these children undergoing T&A" (Smith et al., 2017). 

"As advances in surgical technologies have occurred in the last 35 years, so have the number of techniques for tonsillectomy and adenoidectomy. The cold technique utilizing the Hurd dissector, the Fisher knife and the snare is a time tested technique that has the advantage of less pain, depending upon the amount of cautery necessary to achieve hemostasis. The incidence of secondary bleeding may also be less, but that remains a controversial issue. The disadvantages of this technique include longer surgical time, more surgical blood loss and a higher incidence of primary bleeding within the first 24 hours of surgery" (Wetmore, 2017). 

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 an inpatient admission is not substantiated.