Diagnosis: Papillary carcinoma of the thyroid
Treatment: Inpatient admission
The insurer is denied coverage for inpatient admission.
The denial is reversed.
The patient is a male with a history of diabetes mellitus, hyperlipidemia, essential hypertension and removal of the schwannoma from his neck. The patient presented with a presumptive diagnosis of papillary carcinoma of the thyroid. The patient underwent a total thyroidectomy which took 4 hours and 3 minutes. The operative procedure was finished at 15:35 h. Post-operatively; the patient's pain was controlled with intravenous (IV) fentanyl and opioids. The patient's electrocardiogram (EKG) obtained revealed sinus tachycardia and nonspecific T wave abnormality. The patient was found to have an increased serum lactate at 13:45h it was at 3.6 and at 18:42h, it was 3.14.
The peer reviewed literature is consistent in finding that prolonged operative time results in substantial complications and prolonged length of stay.1, 2 In this case, the patient underwent a 4 hour and 3 minute procedure which is the third longest quintile in the Phan study.2 Studies have shown that "prolonged anesthesia duration is associated with increased odds of complication, venous thromboembolism, increased length of stay, and return to the operating room."2
The patient was found to have an elevated lactate and this did not return to a normal value until the following morning. Elevated lactate is a sign of probable cellular hypoxia.3,4 Thus, with these elevated lactate levels as well as this patient's history of diabetes and this patient's electrocardiogram (EKG) showing sinus tachycardia and non-specific T wave abnormalities, there was clinical concern of probable anoxic and/or cardiac complications. Thus, it was medically appropriate and necessary to observe the patient until this patient's lactate value returned to normal.
The patient was at considerable risk for post-operative complications due to his diabetes, his abnormal EKG findings, prolonged anesthesia1,2 and his increase lactate levels.3,4 To have discharged this patient sooner would have been contrary to best medical practice. Thus, inpatient admission was medically necessary for this patient.
The health plan did not act reasonably with sound medical judgment, and in the best interest of this patient.
The carrier's denial of coverage for the inpatient admission should be reversed. The medical necessity is substantiated.