Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sarcoma with Lung Metastasis
Treatment: Inpatient Stay
The insurer denied the Inpatient Stay. The denial was upheld. 

This is a middle aged male who transferred from another facility for continued management of issues related to his disease process; he was undergoing chemotherapy.  Upon arrival he was noted to be intermittently confused, coughing, had shortness of breath, scattered rhonchi, decreased breath sounds at bases, and left shoulder sharp pain with a pain score of 8/10.  He has a history of sarcoma with lung metastases, prostate cancer, high-grade pleomorphic sarcoma of the left abductor compartment of the left lower extremity with anxiety, as well as depression, diabetes, obstructive sleep apnea, asthma, chronic hypoxic respiratory failure and pneumonitis.  Infectious Disease consulted the patient with recommendations that included intravenous antibiotics, and resuming oral steroids.  He had complaints of throat pain and dysphagia, a surgical consult was ordered.  A computerized tomography of his of chest, abdomen and pelvis showed slightly increased right pulmonary metastases, right pleural-based metastasis, and supraclavicular lymphadenopathy, as well as unchanged large left upper lobe paramediastinal mass with associated consolidation or atelectasis.  The proximal superior vena cava (SVC), left subclavian, and left innominate veins were thrombosed with subcutaneous venous collaterally in the anterior chest wall.  Speech and swallow team evacuated the patient revealing moderate esophageal phase dysphagia and retrograde flow into the pharynx.  He remained on a mechanical soft diet with thickened liquids.  He was instructed to follow up with the speech and swallow team for further recommendations.  He continued to express concerns regarding the restriction of his diet and continued treatment.  Supportive care was in to assess his needs.  It was documented that the patient remained anxious about his condition and that he remained at risk for aspiration.  A psychiatry consult was order.  Supportive care discussed hospice services with him.  The patient agreed to transfer to hospice services for management of his continued symptoms related to his medical conditions and prognosis. 

According to current literature, a patient may be admitted to inpatient services when the patient has a chemotherapy complication, they are at a high risk for infection, there is thrombotic complication, there is hyperviscosity syndrome, gastrointestinal complication, pathologic fracture with major instability, neurologic complication, malignant effusions, or there is tumor related complications.  Additionally, a patient may be admitted for palliative care.  

Within the documentation it was noted the patient was transported from another facility.  The patient was treated at a prior facility.  The patient at the time of transfer was noted to be back at baseline.  The patient was receiving oxygen 4 liters and was doing well.  The patient did have complaints of shoulder pain; however, he attributed it to the bumpy ride.  The patient was transported initially for further management.  The patient did undergo multiple laboratory and diagnostic studies and had multiple complaints throughout the entirety of the stay.  However, it was noted that the patient did not have any major complaints.  The patient was noted to have a history to include a left vocal cord paralysis, and this was not a new finding.  While it was noted that the patient was appropriate initially for further care and observation, the patient was not appropriate for inpatient services.  It was noted that the patient had participated in physical therapy services and was able to ambulate with a caregiver assist pushing his IV pole.  He had good pain control and was able to utilize medication as needed for anxiety.  He was comfortable on exam.  

Based on the above, the medical necessity for continued inpatient stay is not substantiated.  The insurer's denial is upheld.