Diagnosis: Thyroid nodule.
Treatment: Inpatient admission.

The insurer denied the inpatient admission. The denial is overturned.

The patient is a male with a history of diabetes on metformin and glimepiride. He presented with complaints of swallowing discomfort for one year that increased over the prior 3 months. The patient saw ENT (otolaryngology), who palpated a thyroid nodule. Ultrasound confirmed a left thyroid nodule. Biopsy revealed thyroid cancer. The patient had a BMI (body mass index) of 36. The note reports that the plan was for a total thyroidectomy.

On admission, the patient was noted to have a glucose of 302. The patient had a left hemithyroidectomy and was noted to be tachycardic and hyperglycemic postoperatively. His oral medications were held because of the surgery. He was started on Lantus and sliding scale lispro. The tachycardia was believed to be postoperative pain and volume depletion. He was started on intravenous fluids and treated with pain medications. The patient was admitted for treatment of the hyperglycemia, tachycardia, and pain. The patient continued to have postoperative pain requiring morphine every 3 hours. The patient was unable to tolerate swallowing his meals. Fasting glucose continued to be elevated despite poor PO (oral) intake. The patient was unable to speak with a full voice.

The patient's level of care was changed to inpatient from observation. The patient began tolerating oral intake and had less pain. The patient was safe for discharge.

Yes, the Inpatient admission was medically necessary.

In most patients, thyroidectomy can be a same-day procedure [1, 2, 3, 4]. In certain patients, the hospitalization must be prolonged due to complications for complicating diagnoses. Whenever there are complications preventing the patient from being able to hydrate themselves orally, hospitalization for treating these complications until the patient is able to take PO (oral) intake is necessary.

In this case, the patient had postoperative pain, nausea, tachycardia, hyperglycemia, and the patient was unable to orally hydrate. He required treatment with intravenous fluids and insulin until the patient was able to hydrate himself. The request is consistent with generally accepted standards of medical practice. The inpatient admission was medically necessary.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient, as the request was medically necessary as described above.