Diagnosis: Shortness of breath.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.


The patient is a former smoker who stopped many years ago, with a history of hyperlipidemia and positive coronovirus disease (COVID) antibodies, who presented with increasing shortness of breath. A computed tomography (CT) scan showed a partly solid ground glass opacity in the right lung apex that measured 1.4 centimeters (cm) x 1.4 cm with a .5 cm x .6 cm solid component. A fine needle aspiration (FNA) was suspicious for malignancy. A positron emission tomography (PET) scan showed a fludeoxyglucose (FDG) avid lesion in the right upper lobe (RUL) (standard uptake value [SUV] of 1.2) corresponding with the lesion that was biopsied. The patient was taken to the operating room and underwent a flexible bronchoscopy and right video-assisted thoracoscopic surgery (VATS) resection of the RUL lesion with a Level 4 dissection of the lymph nodes. A frozen section revealed adenocarcinoma with a negative margin. An epidural catheter was in place to help with pain management. The patient had an arterial line, Foley catheter, and chest tube in place postoperatively. The patient had pain, was nauseous, and short of breath. She improved and was discharged with follow-up. The inpatient stay was denied and is under review for medical necessity.

The requested health service/treatment of inpatient stay is medically necessary for this patient. Moderate-severe postoperative pain following VATS is not rare - the incidence of moderate-severe pain is 12.7% within the first 24 hours and 15.6% within the first 48 hours after surgery. Postoperative analgesia is a necessary part of the anesthetic plan. Per the Milliman Care Guidelines (MCG) Health Inpatient and Surgical Care 24th Edition Thoracotomy with Biopsy or Miscellaneous Procedures by Video-Assisted Thoracic Surgery (VATS), the patient meets the clinical indications for the procedure which is indicated for one or more of the following: Thoracoscopic lung or pleural biopsy for diagnosis of 1 or more of the following: pulmonary lesion. The goal length of stay is ambulatory or 2 days postoperative. Pain management was the major issue in this patient. The patient had an epidural in place for pain management and could not be discharged with an epidural in place. Medications were adjusted and the patient was discharged (2 days postoperative). This is an acceptable time course post procedure per the MCG Health Inpatient and Surgical Care 24th Edition. The requested health service/treatment of inpatient stay was medically necessary for this patient.