Diagnosis: Vocal fold paralysis
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay
The determination is upheld.

The patient was diagnosed with a malignant thyroid neoplasm and underwent a thyroidectomy. This resulted in paralysis of the right recurrent laryngeal nerve. Her symptoms include dysphonia and dysphagia. Her exam revealed a right true vocal fold paralysis. She underwent a flexible laryngoscopy with a right implantation thyroplasty and a right pharyngoplasty. She was not intubated for this procedure. She did well postoperatively and was admitted overnight for airway monitoring and having had no sequalae, was discharged. At issue is the medical necessity of an inpatient stay.

The requested health service/treatment of an inpatient stay is not medically necessary for this patient based upon the clinical information provided and the peer reviewed medical literature.
Clinically, the patient was admitted for airway monitoring after medialization thyroplasty. Postoperatively, she remained afebrile. Her oxygen saturations ranged from 96 to 100% on room air and it is documented that she was breathing comfortably. Her voice was improved. She was able to tolerate the mechanically soft diet ordered; she experienced no postoperative bleeding. Although it is noted that the patient had hypotension postoperatively, this did not persist and she was not seen in consultation for persistent hypotension. Therefore care could have been provided at a lower level than inpatient.
According to Ekbom et al (2019), same day discharge has become more common in medialization thyroplasty over the preceding 10 years and in a series by Attalah et al(2019), the authors concluded that the procedure was safe and effective with no postoperative complications noted. In a study by Chau in 103 patients, the adverse effects during and immediately following unilateral medialization laryngoplasty is very low and that patients can be discharged on the day of surgery without any geographic restrictions, such as staying near the facility in which the the procedure was performed.
Based upon the clinical information and the peer reviewed medical literature, admission postoperatively was not medically necessary.