Persistent Pain After an Outpatient Procedure

Submitted by Alyssa Riley, MD
Physician Advisor, Dell Children's Medical Center

Type of Denial: Medical Necessity Retrospective
Age: 14 years
Insurance: Commercial
Length of Stay: 4 days
Reason for being Hospitalized: 14 yo F hospitalized following left shoulder arthrodesis for post-procedure IV antibiotics and pain control.

Hospital Course:

Intra-operatively and following procedure, the patient was treated with 24 hours IV cefazolin for surgical prophylaxis. Patient's pain was treated with oral Tylenol q6h, ibuprofen q6h, oral diazepam q6h, and gabapentin BID. Patient's pain was uncontrolled, and she received additional pain control on days 1 and 2 with intermittent oral oxycodone. On day 3, with pain control still inadequate, oral oxycodone was scheduled every 4 hours. By day 4, pain control was adequate and patient was discharged to home.

Appeal Strategy:

Commercial payor medical director wanted to deny inpatient level of care since pain medications used were not administered intravenously. I provided clear evidence from the chart documentation that described an inability to control pain with the current strategies (scheduled Tylenol, ibuprofen, diazepam) along with a clear change in the plan of care to address pain management (moving oxycodone from 'as needed' to 'scheduled') and was able to convince the medical director that this was sufficient management for inpatient level care as the hospitalization exceeded a 'reasonable observation period' for ongoing care.