Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pulmonary Metastatic Disease
Treatment: Inpatient Stay
The insurer denied: Inpatient Stay
The denial is: Upheld

The patient is a female with metastatic colon cancer. She is status post chemotherapy and sigmoid resection with recurrence as a right lower lung nodule with subsequent wedge resection with recurrence with paratracheal and mediastinal disease status post radiation in the setting of superior vena cava (SVC) syndrome, starting chemo again with recent admission to the hospital for a port change complicated by post-procedural cardiac tamponade and chronic SVC occlusion and presumed post radiation pericarditis.

The patient received 2 milligrams (mg) of morphine intravenous (IV) in the emergency room and another 4 mg of morphine IV. The patient was admitted to inpatient level of care. Admission history and physical noted plan to continue morphine 2 mg every 4 hours as needed for pain, obtain radiation oncology consult, obtain palliative care consult, continue Zofran and Benadryl as needed. The patient had a medical oncology consult also recommending palliative care consult for pain management and radiation oncology consult to discuss utility and benefits of proton therapy. The patient received 4 mg of IV morphine and on then the patient received 2 mg of IV morphine. The patient was seen in consultation by radiation oncology and offered palliative radiation and was seen by palliative care with recommendation to start Morphine Sulfate (MS) Contin 15 mg twice a day with Lyrica 50 mg 3 times daily. There was a plan for Computed Tomography (CT) simulation as an inpatient. There was a plan to discharge (DC) to home but patient had blood pressure of 85/56 and episode of nausea and vomiting, and decision was made to keep the patient overnight. The patient was given IV fluids and the patient was discharged to home with further outpatient treatment and follow up. The subject under review is the medical necessity for the inpatient stay.

The inpatient stay was not medically necessary. The patient presented to the emergency room with complaints of left-sided chest pain worse with breathing. The patient's vital signs were stable except for a slightly low blood pressure of 98/56 and an initial heart rate of 110 which improved with pain control and IV fluids in the first 24 hours. The patient appropriately underwent laboratory, cardiovascular and imaging studies showing stable labs with mild anemia, normal Electrocardiogram (EKG), negative troponin, and CT scan of the lung without evidence for pulmonary embolism. CT scan showed evidence of worsening metastatic disease of the left ribs which explain the patient's presenting chest pain. Although IV morphine was ordered every 2 hours the patient received it less than every 8 hours during the first 24 hours and was transitioned to oral morphine. The patient's labs remained stable throughout her hospital stay with stable hemoglobin and hematocrit. The patient had 1 episode of hypotension, nausea, and vomiting that responded with IV fluids and antiemetics the day prior to discharge. The patient had consultation with medical oncology, radiation oncology, and palliative care none of which were urgent nor was there an urgent need for procedure or surgery. The patient did not require complex IV therapy. There was no documentation in the admitting history and physical of risk of acute decompensation, need for complex IV therapy nor need for urgent consultation or procedure. There was no documentation in the admitting history and physical for medical necessity for inpatient care or hospital stay greater than 2 midnights. The patient could have been managed at a lower level of care status.