Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Multiple myeloma. 
Treatment: Inpatient hospital admission.
The insurer denied coverage for days 4 and 5 of the inpatient hospital admission.
The denial is upheld. 

This is a male patient with a past medical history of type 2 diabetes mellitus, hypertension, hyperlipidemia and lambda light chain multiple myeloma. The patient received a blood transfusion and erythropoiesis-stimulating agents due to a hemoglobin level below 7. The patient presented to his treating physician at the clinic for an evaluation and second opinion. The patient was still experiencing anemia and fatigue, and there were concerns for progression of his multiple myeloma disease. The patient was admitted from the clinic to the Hospital for an expedited work up of multiple myeloma. The patient also reported having new chest pain and dyspnea up until a few days prior to the admission. 

The patient was followed by Cardiology. The patient's electrocardiogram (EKG) showed inferior Q waves and non-specific ST and T wave abnormalities. The patient's echocardiography report noted mild mitral regurgitation with no significant pericardial effusion seen. The patient's bloodwork and telemetry monitoring were maintained. Cardiology determined there was no need for a cardiac catheterization as the patient was not having active chest pain, and his troponin levels were negative.  

On day 3 of admission, the patient's lab work was significant for a white blood cell (WBC) count of 1.1, red blood cell count of 2.26, hemoglobin of 8.1, hematocrit of 23.5, platelet of 104 and absolute neutrophil count of 0.1. On day 4 of admission, the patient's lab work was significant for a WBC count of 0.9, absolute neutrophil count of 0.1, hemoglobin of 7.6, and hematocrit of 22.6 and a platelet count of 102. The patient received 1 unit of packed red blood cells. The notes from day 4 of admission documented that the patient was doing well except for weakness with no complaints of chest pain and was able to ambulate around the room with no shortness of breath. There were no plans for cardiology intervention.  

The patient was planned for chemotherapy on day 6 of admission and bone marrow treatment on the same day. The patient was to start what is considered outpatient chemotherapy as an inpatient. On day 5 of admission, the patient's lab work was significant for a WBC count of 1, absolute neutrophil count of 0.2, hemoglobin of 8.4, and hematocrit of 23.7 and platelet of 103. The patient also received a physical therapy (PT) evaluation for bilateral leg weakness. The patient was started on chemotherapy on day6 of admission following a bone marrow biopsy and completed a treatment cycle. The patient was discharged on day 11 of admission with a recommendation to follow-up with Cardiology as an outpatient. There was also a recommendation by the rehabilitation team for home PT and occupational therapy (OT) services. The patient also needed frequent follow up at the clinic for fluid volume assessment as part of an ongoing process.

On the dates of service in question (days 4 and 5 of admission) the patient was clinically stable with chronically low blood counts that did not require acute intervention. There was no further plans for cardiac intervention and the patient was waiting to start what is described in the notes as outpatient chemotherapy as an inpatient. There were no interventions on this date of service that warranted inpatient level of care. The patient was clinically stable waiting to start what is described as outpatient chemotherapy. Thus, these dates of inpatient service were not medically necessary for this patient. 

The health plan acted reasonably with sound medical judgment, and in the best interest of the patient.
 
The carrier's denial of coverage for days 4 and 5 of the inpatient hospital admission should be upheld. The medical necessity is not substantiated.