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202004-127323

2020

Fidelis Care New York

Medicaid

Cancer

Inpatient Hospital

Medical necessity

Overturned

Case Summary

Diagnosis Lung Cancer
Inpatient stay
The insurer denied the inpatient stay
The determination is overturned.

The patient was being evaluated for hydronephrosis by a computed tomography (CT) scan of the abdomen which showed a left lower lobe (LLL) lung lesion. The patient had a significant uterovaginal prolapse for which she was scheduled for colpocleisis . Workup for the LLL included a needle biopsy done which confirmed the suspicion that this was a primary lung cancer.
She was admitted for a left lower lobectomy and mediastinal lymph node dissection with robotic approach. The patient was in the intensive care unit (ICU) postoperatively. She had chest tubes to suction then water seal for 24 hour which were removed on postoperative day (POD) number 2. The patient was discharged. At issue is the medical necessity of an inpatient stay.

The inpatient stay was medically necessary. It is standard of care for an inpatient stay after this procedure. This patient was in the cardiothoracic intensive care unit (CTICU) postoperatively where she underwent extubation, pain management, and monitoring. Her age placed her at a high risk for possible postoperative complications. Serial chest x-rays (CXR) showed the development of a postoperative pneumothorax (PTX) on postoperative day (POD) 1, then POD 2 the CXR showed a decrease in the size of the PTX but still present. Pain management and monitoring was continued to be needed. Chest tubes were then removed and then monitored for issues. This level of care cannot be provided at a lower level than inpatient for this type of procedure and postoperative care.

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