Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Invasive Carcinoma of the Left Breast, Elevated Blood Pressure status post Bilateral Mastectomy
Treatment: Inpatient admission
The health plan denied the inpatient admission.
The health plan's determination is upheld.

The patient is a female who presented to the hospital with the diagnosis of left breast cancer. The patient's comorbid health conditions included coronary artery disease status post coronary bypass, type 2 diabetes, hypertension, and cardiomyopathy. At the time of presentation, the patient was without fever and her vital signs were normal. She was treated with a bilateral simple mastectomy. The operative dictation and the anesthetic record describe an uncomplicated procedure. Two surgical drains were placed in the area of the operative field. The pathology report documents right benign breast tissue and residual ductal carcinoma in situ (DCIS) of the left breast.

The patient was treated with post-surgical monitoring, intravenous (IV) fluids, analgesia, and antiemetics. The patient's immediate post-surgical recovery was uncomplicated. The patient had stable vital signs and her pain was controlled post-operatively. The patient's diet was advanced. The patient remained clinically stable and was discharged from the inpatient setting the day after surgery. 

Milliman Care Guidelines (MCG) for Ambulatory exception criteria 26th edition is referenced in the health plan's denial letter dated. These MCG Guidelines are included with the review material also.

The health plan in its determination of medical necessity acted reasonably, with sound medical judgment and in the best interest of the patient. An inpatient level of care was not medically necessary for the patient. The patient presented to the hospital with the diagnosis of left breast cancer. She underwent bilateral simple mastectomies as a scheduled surgical procedure. There is no documentation of hemodynamic, pulmonary, neurological, or a metabolic reason for an acute inpatient level of care. The records support that the patient could have been appropriately treated with an ambulatory status as noted in the referenced MCG.

Acute inpatient hospital admission was not medically necessary for the patient as the care and treatment provided could have been rendered at an alternate level of care. An ambulatory status would have provided for perioperative care and monitoring, provision of post-surgical monitoring, drain management, provision of appropriate analgesia, and overnight care. In this case an ambulatory status would have satisfied the clinical needs of the patient.

The inpatient admission was not medically necessary as the records do not document hemodynamic instability, sepsis or toxicity, significant electrolyte imbalance, bleeding, or surgical complications of the procedure that required inpatient care. The patient tolerated oral hydration, a diet and medication and the patient's pain was well controlled following surgery.

An alternate level of care would have appropriately provided for pre-surgical assessment, bilateral simple mastectomies and post-surgical monitoring. The inpatient hospital admission was not required or medically necessary in this case as this level of care was not in accordance with generally accepted standards but is equally effective as the service of ambulatory care.