Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Neuroendocrine Tumor

Treatment: Inpatient admission	

The insurer denied coverage for inpatient admission

The denial is upheld

The patient has been diagnosed with a neuroendocrine tumor. The patient presented for an elective removal of neuroendocrine tumor via endoscopic ultrasound. The patient was admitted for post-procedure monitoring and discharged. The request is for inpatient admission is under review.

The inpatient admission is not considered medically necessary for this patient
The patient was admitted for a procedure and discharged next day. The patient was not hemodynamically unstable. There was no persistent vomiting or dehydration, inability to maintain oral fluids, or acute pain requiring inpatient management. The provided documentation does not show that there were any complications from the procedure or anything that would qualify as meeting inpatient admission requirements. The patient could have been managed in observation. As such, the request is denied.

"Observation was meant to be a short period of time for providers to assess whether patients required admission for inpatient care, or could be discharged. Typically, this was meant to last fewer than 24 hours and only rarely spanned more than 48 hours" (3).

"Neuroendocrine tumors, gastrointestinal stromal tumors, and granular cell tumors accounted for 38% of the procedures, with a 100% rate of en bloc resection and 65% of R0 resection; Most procedures (59%) were performed in an ambulatory setting, with patients discharged on the same day. Most of the admitted patients were hospitalized for 24 h (70%), and the longest admission time was 10 days. Two patients developed low-grade fever, one patient had minor bleeding detected during same-day second-look endoscopy, and one patient had bleeding after discharge needing readmission.  Surgery or blood transfusion consequent to an endoscopic submucosal dissection (ESD) adverse event was not needed in any case, and procedure-related mortality was 0%" (1).																
"Neuroendocrine Tumors (NETs) of the gastrointestinal tract are classified as tumors of the stomach, duodenum, small bowel, appendix, colon or rectum. These account for approximately 7% of all NETs are divided into three different types: Type 1 associated with chronic atrophic gastritis, type 2 associated with Zollinger-Ellison syndrome, and a sporadic type 3. Most of them, estimated 70%-80%, are type 1 and-non aggressive. However, the typical appearance is in multiple lesions. Treatment is dependent on tumor size, depth of infiltration and gastrin dependency, as well as the presence of metastasis. Standard treatment of type 1 lesions < 1 centimeter (cm) is endoscopic removal and observation" (2).

"The time of discharge after endoscopy will depend on the type of procedure and anesthesia administered, complications during and after the procedure, and any underlying clinical conditions of the patient. Video endoscopy is an important modality for the diagnosis and treatment of various gastrointestinal diseases. Most endoscopic procedures are performed as outpatient basis, sometimes requiring sedation and deeper levels of anesthesia" (4).

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 the inpatient admission is not substantiated.