Appeal type: Medical necessity
Decision: Overturned

Diagnosis: enlarged tonsils and adenoids

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned
 

According to the clinical records, the patient is a toddler who presented with a history of enlarged tonsils and adenoids. He has a history of sleep-disordered breathing. Enlarged tonsils and adenoids were noted on examination. He was taken for adenotonsillectomy and ear tube placement. He was admitted after the procedure for postoperative airway monitoring given his sleep history and age. The request of this review is to determine if admission was medically necessary.

Full hospital admission is considered medically necessary for this patient. The patient is under 3 years of age. The available literature supports overnight admission after the procedure; tonsillectomy for airway monitoring. This is for monitoring of pain, oral intake, and respirations. Children under 3 are at a higher risk of complication given the inability to adequately communicate after the procedure.

According to Werle et al (2003), "Eighty-two patients (87%) underwent tonsillectomy and adenoidectomy (T&A). Twelve patients (13%) underwent tonsillectomy without adenoidectomy. Patient ages ranged from 12 to 23 months (mean 19.6+/-3.1). Indications included obstructive sleep apnea (OSA) in 51 patients (54%), chronic or recurrent tonsillitis in 30 (32%), both OSA and infection in 11 (12%), and acute tonsillitis with airway obstruction in two (2%). Comorbid conditions were numerous. Preoperative polysomnograms were obtained for eight patients (8%). Hospital stays ranged from 4 hours to 16 days. Complications included hemorrhage in four patients (4%) and pneumonia in two (2%). Oxygen was required after discharge from the recovery room in 27 patients (29%), with seven more (7%) requiring either reintubation, continuous positive airway pressure, or nasopharyngeal airways. Of the 88 patients on oral diets, only five (5%) took longer than 24 hours to resume oral intake. Two patients (2%) experienced significant emesis after surgery. Four patients (4%) required treatment for dehydration after discharge."

According to Biadsee et al (2023), "Ninety-two children were included; mean age of the whole cohort was 44.5  21.9 months. Thirty-five (38%) children were 3-years old or younger and n = 57 (62%) were older than 3 years old, with no significant statistical difference in sex (p = 0.22). Mean age in the younger group was 25.7  6.9 months, and 56.1  20.1 months in the older group. In total we had 7 children with post-operative complications; 4 with fever, 3 with low intake. There were no major interventions recorded in either group. The complications were more common in the older group (n = 5) than the younger group (n = 2) without a statistical significance (p = 0.59). There were no differences in Visual Analog Scale (VAS), use of painkillers, oral intake, urine output, oxygen saturation and tachycardia among the two groups."

According to Belyea et al (2014), "Overall complication rate in the study group was 9.4% (12 of 127). Early complications (3.1%) were respiratory related, while late complications (6.3%) were due to dehydration and hemorrhage. Comparable complication rate was observed in the control group (8.7%, P>0.05); early complication rate of 3.1% and late complication rate of 5.5% was ascertained. Similar types of complications occurred in the control group."

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for full hospital admission is substantiated.