Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Wilms' tumor

Treatment: Full hospital admission

The insurer denied coverage for full hospital admission

The denial is upheld

This involves a pediatric patient diagnosed with a Wilms' tumor who presented to the emergency room with a temperature of 101.1 degrees Fahrenheit. The report stated that the patient was being treated with chemotherapy for the tumor and was neutropenic on the most recent laboratory study with a white count of 0.4 and 65% (percent) neutrophils. There were no other symptoms reported since the onset of the fever besides fussiness. The patient had a port in place and after the patient's mother contacted the oncologist, the patient was recommended to go to the emergency department, get bloodwork and receive ceftriaxone. The patient was given a bolus of fluids and ceftriaxone with no other symptoms associated with the fever. Bloodwork showed pancytopenia with plans to defer transfusion as the patient was having no symptoms consistent with anemia. The plan was to admit the patient to medicine services for ongoing management given the absolute neutrophil count was severely low. The patient remained on inpatient status until the patient was discharged the following day after a period of hemodynamic stability. The patient received a notice of adverse determination regarding the inpatient stay stating that there were no severe problems warranting a full hospital admission. This review pertains to the denial of coverage for the full hospital admission.

The healthcare plan acted reasonably and with sound medical judgment and in the best interest of the patient.

The Milliman Care Guidelines have stated that clinical decisions for admission to inpatient care for pediatric patients undergoing chemotherapy may include those who require aggressive hydration that cannot be managed in an infusion center, with a prolonged marrow suppression, aggressive regimen requiring frequent monitoring which cannot be done in an infusion center outpatient setting, those who require prolonged continuous infusion coordination of multiple infusions, and intra-arterial chemotherapy. Admission may also be indicated when there is either anaphylaxis to prior therapy, acute leukemia with blast crisis, intraperitoneal chemotherapy, chimeric antigen receptor T-cell therapy, asparaginase therapy, or other agent with anticipated toxicity that requires inpatient care. Inpatient treatment may also be recommended for those individuals who have cardiovascular complications, respiratory complications, gastrointestinal complications, skin complications, neurologic complications, renal or metabolic complications, or anemia requiring inpatient admission. Alternatives to admission include treatment in outpatient care infusion center, clinic, medical office, home, or other outpatient setting. The information provided for the review noted that the patient presented with a fever and notation that the patient was undergoing chemotherapy for treatment of a Wilms' tumor. However, the evidence did not support that the patient's care cannot be rendered safely and effectively on an outpatient observational basis. While the patient was noted to have neutropenia, the patient was not symptomatic, and responded favorably to intravenous fluids and intravenous antibiotics. It was therefore determined that the inpatient care was not medically necessary.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the full hospital admission is not substantiated.