Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cough; shortness of breath; fever.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is overturned. 

The patient is a male teen. He presented to the ED (emergency department)  with one week history of dry cough with shortness of breath and isolated fever to 102 responsive to Tylenol. He also reported a lump on his left neck for the past month, feeling hot at night, and intentional weight loss. He was seen by his pediatrician who ordered an ultrasound of the neck mass revealing bilateral cervical chain lymphadenopathy. He was referred to the ED (emergency department) for further management.

The patient's Rapid Strep and Covid testing were negative. Vital signs included temperature 37.2, heart rate 102, respiratory rate 18, 98% saturation in room air, and blood pressure 138/78. Examination was significant for no acute distress, moist mucous membranes, left submental lymphadenopathy diffuse without fluctuance, left anterior lower cervical lymphadenopathy 3-4 cm (centimeters) wide with no overlying erythema or tenderness, clear lungs, no abdominal tenderness, and non-focal neurologic exam. Laboratory evaluation revealed normal WBC (white blood cell) count 9.6K, mild anemia (hemoglobin 10.2), thrombocytosis (platelets 469K), elevated LDH (lactate dehydrogenase) (599), normal uric acid (3.9), and negative Covid testing. Chest x-ray was significant for extensive bilateral mediastinal and hilar lymphadenopathy suspicious for a neoplastic process such as lymphoma. Brain CT (computed tomography) was unremarkable. Neck CT (computed tomography) revealed extensive and confluent bulky lymphadenopathy of the inferior cervical chain bilaterally with extension into the mediastinum and hila, and bulky lymphadenopathy resulting in severe narrowing of the trachea with minimal luminal diameter of 6mm (millimeters). Chest CT (computed tomography) revealed at least a dozen solid and ground glass pulmonary lesions the largest measuring 1.1 cm (centimeters), and abdominal CT (computed tomography) revealed a 2 cm (centimeters) low-attenuation liver lesion with multiple low-attenuation splenic lesions.

The patient was admitted to the PICU (pediatric intensive care unit) for airway monitoring in the setting of significant tracheal narrowing with plans for excisional biopsy the following day. He was taken to the OR (operating room) the following day for excisional biopsy of an enlarged lymph node adjacent to the left sternocleidomastoid under moderate sedation, resected without complication and sent to pathology. Following the biopsy, he began treatment with parenteral corticosteroids. Flow cytometry had features of classical Hodgkin lymphoma.

The patient was deemed stable for transfer to the pediatric floor with plans for additional testing. Transfer orders included continuation of corticosteroids, albuterol as needed, outpatient PET (positron emission tomography) CT (computed tomography), echocardiogram prior to discharge, and repeat chest x-ray. He was evaluated by Speech Pathology and cleared for a regular diet for age with thin liquids and appropriate aspiration precautions. His tachycardia and cough improved. Echocardiogram was unremarkable. Repeat chest x-ray revealed slight interval decrease in size of the anterior mediastinal mass, with normal appearance of the trachea on AP (antero-posterior) projection. The patient was subsequently deemed stable for discharge home to follow-up with Oncology and complete his course of corticosteroids.

Yes, the Inpatient admission was medically necessary and appropriate for this patient.
Neck masses in children can be placed into three general categories: developmental, inflammatory, and neoplastic. Congenital masses would include thyroglossal duct cysts, branchial cleft cysts, dermoid cysts, vascular malformations, and hemangiomas. Inflammatory lesions would include infectious lymphadenitis and reactive lymphadenopathy. Neoplastic masses are most likely to be benign, and include pilomatrixomas, lipomas, fibromas, neurofibromas, and salivary gland tumors. Malignant lesions are rare in children, but when present include lymphoma, rhabdomyosarcoma, thyroid carcinoma, and metastatic nasopharyngeal carcinoma.

Diagnostic studies include testing for infectious diseases (EBV [Epstein Barr virus] titers, HIV [human immunodeficiency virus], CMV [cytomegalovirus] titers, PPD [purified protein derivative] for tuberculosis, etc), ultrasonography if a developmental mass is suspected, and CT (computed tomography) with contrast for suspected malignancy or deep abscess.

Therapy is of course dependent on the etiology, ranging from antibiotic therapy to incision and drainage to surgical excision. One of the big concerns with neck masses that occur in conjunction with mediastinal masses is lymphoma, either Hodgkin's or non-Hodgkin's. With the anterior mediastinal masses that occur with lymphoma, there is risk of airway compression and obstruction.

Patients may present with worsening cough and shortness of breath, as with this patient, they may be relatively asymptomatic, or they may be in acute respiratory failure. The risk is significant, and these patients must be monitored very closely for signs and symptoms of acute decompensation. Typically, this involves admission to the ICU (intensive care unit), biopsy under conscious sedation rather than general anesthesia, conservative pain management, and cardiorespiratory monitoring. This level of care, the care provided to the patient in this case, is most consistent with acute inpatient level of care. Lower level of care would not have been appropriate or consistent with the current standard of care.