Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fever.

Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is upheld.

 
The patient is in a clinical trial for myeloma. She came to the emergency room (ER) for fever, tachycardia, hypotension, and for further workup. The patient was admitted and had an infectious workup, the patient was treated with intravenous (IV) cefepime, IV vancomycin, and IV azithromycin. The patient received Intravenous immunoglobulin (IVIG) and was discharged with plans to complete fluconazole for thrush and Valtrex for herpes simplex. The absolute neutrophil count (ANC) was 3600. She was admitted for the first dose of a clinical trial TRIMM2 (name of study) and at the next visit, had mouth sores, Temperature (T) 100.1 degrees Fahrenheit (F), and a repeat T of 101.5 degrees F. She was hydrated and treated with antibiotics.

Non-neutropenic fever does not demand an admission. This patient's ANC level of 3600 is not considered neutropenic and antibiotics could have been given orally or on an outpatient basis. All symptoms could be treated as an outpatient. Hydration, antibiotics, and close follow-up could all have been done on an outpatient basis. The white blood cell count was adequate for such a plan. Therefore, the request for full hospital admission is not considered medically necessary for this patient.

Krzyzanowska, M. K., Walker-Dilks, C., Atzema, C., Morris, A., Gupta, R., Halligan, R., Kouroukis, T., & McCann, K. (2016), "The search identified eight guidelines that had partial relevance to the topic of the present guideline and thirty-eight primary studies. The studies were mostly noncomparative prospective or retrospective studies. Few studies directly addressed the topic of fever except as one among many symptoms or adverse effects associated with chemotherapy. The recommendations concerning fever definition are supported mainly by other existing guidelines. No evidence was found that directly pertained to the assessment of fever before a diagnosis of febrile neutropenia was made. However, some studies evaluated approaches to symptom management that included fever among the symptoms. Few studies directly addressed information needs and resources for managing fever in cancer patients. Fever in patients with cancer who are receiving systemic therapy is a common and potentially serious symptom that requires prompt assessment, but currently, evidence to inform best practices concerning when, where, and by whom that assessment is done is very limited."

Punnapuzha, S., et al. (2022), "Neutropenic fever is defined as a single oral temperature greater than or equal to 101 F (38.3 C), or a temperature greater than or equal to 100.4 F (38 C) for at least an hour, with an absolute neutrophilic count (ANC) of less than 1500 cells/microliter. In severe neutropenia, the absolute neutrophil count (ANC) is less than 500 per microliter (microL), or the ANC is expected to decrease below 500 cells/microL in the next 2 hours. Febrile neutropenia is the most common serious and common complication of cancer therapy."                                                         

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 full hospital admission is not substantiated.