Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Achalasia 
 
Treatment: Inpatient Admission 

The insurer denied the inpatient admission. The denial was upheld. 

This is a female patient with a history of dysphagia. She reported having the feeling of being full after she ate with associated chest pressure that was only relieved by vomiting. The patient was admitted with achalasia. Prior to the procedure she had an outpatient esophagogastroduodenoscopy (EGD) that revealed esophagitis. She presented to the hospital for a scheduled laparoscopic Heller myotomy and partial fundoplication. She underwent the procedure without complications. Post procedure she had an EGD and an esophagram which showed esophageal dysmotility and retention without extravasation. She was advanced to a full liquid diet with tolerance. She was discharged home. 

Based upon review of the medical records, the inpatient admission was not medically necessary as the patient could have been monitored in a 23-hour observation status. According to MCG, Inpatient and Surgical Care, 23rd Edition: Fundoplasty, Esophagogastric, by Laparoscopy ORG: S-505 (ISC), the Operative Status Criteria is Ambulatory. Extended Stay as defined by Minimal (a few hours to 1 day), Brief (1 to 3 days), Moderate (4 to 7 days), and Prolonged (more than 7 days) with inpatient stay may be needed for: Conversion to open fundoplication procedure; Repair of paraoesophageal hernia required; Patient with high anesthesia risk; Patient with strictures or large hiatal hernias; Operative or postoperative complications, such as wrap herniation, pneumothorax, perforation, hemorrhage, or splenic injury requiring inpatient evaluation and care; Failure to achieve discharge status criteria. There were no criteria based upon these factors that would have warranted inpatient stay. 

Therefore, ambulatory status without inpatient admission was adequate in this case. In addition, the patient underwent the Heller myotomy prior to the fundoplication. A leak test and EGD was done which was unremarkable. An esophagram was done postoperatively that showed no leak. The patient was started on full liquid diet and tolerated her diet. She could have been discharged following observation and tolerance of a liquid diet. 

Finally, MCG Inpatient and Surgical Care, 23rd Edition Ambulatory Surgery Discharge and Complications: Common Complications and Conditions CCC: CCC-044 (ISC) clinical indications for inpatient care include: Surgery or procedure performed on ambulatory basis may require inpatient stay for 1 or more of the following: Preoperative situation, condition, or finding that warrants inpatient stay as indicated by 1 or more of the following: Inpatient care needed for preoperative disease or condition; Emergent procedure; Complex surgical approach or situation anticipated; Procedure is not low risk and patient at high anesthetic risk; Presence of drug-related risk; Inadequate outpatient care situation; Postoperative event, condition, or finding that warrants inpatient stay. There were no indications in this case for inpatient care as the patient could have been monitored in an observation status as she underwent an uneventful laparoscopic esophagomyotomy and fundoplication which is considered an ambulatory procedure. 

The insurer acted reasonably, with sound medical judgment, and in the patient's best interest. 

Based on the above, the medical necessity for the inpatient hospital services is not substantiated. The insurer's denial is upheld.