Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastric adenocarcinoma with esophageal extension
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is upheld.

This is the case of an adult male with a history of gastric adenocarcinoma with esophageal extension, anemia, and diverticulosis. As per the emergency department (ED) provider note the patient was complaining of leaking jejunostomy tube (J tube). The patient reported that a "washer was coming out from underneath the skin at the site of the J tube." The patient noted increased tan colored drainage from insertion site with surrounding redness with visible sutures. The patient attempted to flush J tube and fluids were coming out around the insertion site. The patient reported receiving last chemo (chemotherapy) a few days prior and receives it every 2 weeks. Since taking his chemo he has been able to tolerate small amounts orally and has not had any vomiting. Exam revealed the patient was afebrile. The abdomen was soft around the J tube. Labs included white blood cell (WBC) count 61. X ray of the abdomen revealed J tube with oral contrast present within the jejunum. No definite extraluminal contrast identified. The plan was surgical consult.

Surgical Consult saw the patient and noted the leakage around the tube. The attending noted that the tube was replaced by the resident and confirmed appropriate placement on the tube injection study. No more leak was seen. The patient still had some pain around the tube. Tube feedings were not started yet. The plan was to resume the tube feedings. The WBC was felt to be reactive to steroid and Neupogen. The plan was to monitor and likely discharge home the next day.

Progress notes indicated no extraluminal contrast seen on abdominal x-ray. No acute events overnight. The patient denied fever or chills. 

Progress notes the day of discharge indicated the patient was doing well. The plan was for discharge today as tube feedings continued and were tolerated.

Based upon the information provided, coverage for full hospital admission is not justified as the patient should have been cared for in an outpatient/observation status. The insurer is correct in denying inpatient admission. According to Milliman Care Guideline (MCG) Health General Recovery Guidelines 26th 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. In this case the patient had the tube that same day replaced upon presentation at the bedside and had a negative J tube study thus tube feedings could have been restarted. The patient only needed to be observed and did not need acute care inpatient admission. The elevated WBC was felt to be due to the steroids and Neupogen.

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for inpatient admission is upheld. Medical Necessity is not substantiated.