Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bilateral mastectomy
Treatment: Inpatient admission

The inpatient care was not required or medically necessary. 

This is a female with a medical history of asthma and status post (s/p) bilateral mastectomy five years ago with reconstruction and has been experiencing issues with her breast reconstruction endorsing subjective fever and chills which occurred the night before presentation. She followed-up with her surgeon who informed her that her silicone implants are prone to swelling. He referred her to the emergency department (ED). 

The patient presented to the ED complaining of bilateral (b/l) breast swelling and pain. While in the ER she had a chest x-ray done for chest pain. An electrocardiogram (ECG) showed T- wave abnormality in anterior leads. Lab test results showed low levels of carbon dioxide (CO2).  C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) levels were significantly elevated. She was admitted to plastic surgery for swelling, mastodynia, and breast implant rupture secondary to breast implants. An incision of bilateral breasts with removal of bilateral implants was done. A bilateral capsulectomy and pulsed irrigation was done.  Jackson-Pratt (JP) drains times two were placed. She was discharged home following the procedure.

This female has pain from capsular contractions. She was not septic. She did not have an infection.  Her surgeon performed bilateral implant removals and capsulectomies. New implants were not placed. Capsulectomy and implant removal surgery almost always can be performed as an outpatient procedure. The records do not document any special circumstances such as significant medical co-morbidities, sepsis, infection or a complicated procedure that would justify inpatient admission.  

According to the Milliman Care Guidelines, 22ndt Edition, "General Admission Criteria", Admission is indicated for one or more of the following:
Hemodynamic instability
Hypertension requiring inpatient treatment
...
Severe behavioral health issues

Inpatient monitoring needed; examples include:
- Vital signs, neurologic signs, or vascular checks more frequently than every four hours
- Cardiac or respiratory monitoring beyond the scope (eg, over 24 hours) of observation care
- Pulmonary artery catheter monitoring
- Suspected compartment syndrome
- Cerebral bleeding, hydrocephalus, or vasospasm monitoring
- Increased intracranial pressure or cerebral edema monitoring
- Fetal monitoring

Treatment requiring inpatient care; examples include:
- IV fluid to replace significant ongoing losses (greater than three L/m2 per day)
- High concentration oxygen (greater than 40%)
- Frequent respiratory therapy (more frequently than every four hours) to maintain airflow rates greater than 60% of baseline
- Epidural analgesia (83)
- IV anticoagulation, vasoactive, or antiarrhythmic medication
- Acute thrombolytics (generally require 24 hours of observation)

Emergency procedures needed

This patient did not have any of these conditions. She had pain following the surgery but was hemodynamically stable. Her pain was controlled with analgesics. She did not have any significant physiologic or surgical complications following the procedure. She could have been managed at an observation or outpatient level of care.

The patient could have been managed at an observation or outpatient level of care.