Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Endometrial cancer with metastasis to brain 

Treatment:  End of Life Care

The insurer denied coverage for End of Life Care at a specified hospital.  The denial is upheld. 

This patient is a female with endometrial cancer with metastasis to brain, recent abdominal mass, recent hemorrhagic stroke, hypertension and anemia (treated with bi-weekly blood transfusions, per daughter).  The patient was admitted after being found at home unresponsive.  Neurosurgery was consulted and evaluated the patient.  The patient was non-verbal, but communicated with head nodding; able to comprehend and follow commands.  Per Palliative Progress Note, the patient is receiving Levetiracetam oral; Piperacillin/Tazobactam intravenous (IV) every eight hours and Vancomycin IV every twelve hours for sepsis, Oxycodone IR every four hours as needed (PRN) for moderate to severe pain.  Her white blood cell (WBCs) counts were 22.98 and 23.76. Her hemoglobin (Hgb) was 5.7, anemia likely related to blood loss in setting of abdominal mass communicating with small intestine.  Her oral intake was poor, and she was noted to have difficulty swallowing and urinary retention.  

Per case notes on a specified date, oncology recommended palliative care.  The patient was a full-code, per her family who were interested in inpatient hospice at a specified hospital versus nursing home with hospice.  This patient can safely and appropriately receive care at the current facility.

The hospital that the family wishes the patient to be transferred to offers a unique type of a hospice, and acute care hospice, with the ability to provide supportive care, as well as transfusions and antibiotic therapy.  It does appear in the notes that there are issues surrounding tube feedings.  However, it is not clearly stated in the provided documentation why this type of care is being sought, what the motivation for this transfer is.  It cannot be said that the requested hospital would be more appropriate than the current facility in which the patient is receiving treatment, as the current facility is a hospital and can provide whatever services are needed at this time.   
   
Effective palliative care begins with guiding patients and their loved ones to make informed decisions.  Palliative care professionals educate patients about their treatment options.  They assist with the development of plans called advance directives to designate surrogate decision-makers health care proxy, power of attorney to carry out patients' wishes if they are unable to voice them.  The problem is that, without a basic understanding of these terms, clinicians who do not work in palliative care lack the knowledge and confidence to provide such education, and patients end up without a voice in their own care plans (Wilmont 2015).    

Medical admission for End of Life Care to the specified hospital from the date specified to present is not medically necessary.  Palliative care goals are not indicated in the provided documents to support that care can only be provided from the specified hospital to meet care goals.
                                                  
The carrier's denial of medical admission for End of Life Care from a specified date to present is upheld.  The medical necessity is not substantiated.