Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Breast cancer 
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission.
The denial is upheld.

The patient has the medical diagnoses of noted severe schizophrenia, asthma, substance abuse of unknown type, and breast cancer. The patient presented to the emergency room (ER) with complaints of a foul-smelling left breast mass. The patient recently started chemotherapy and left the hospital against medical advice (AMA) at that time. During the current admission, the patient was given one dose of Vancomycin. Radiation therapy recommended chemotherapy and imaging of the brain. The patient left AMA again. 

The treating provider stated that the patient presented to the ER with complaints of a breast mass with a nonhealing wound and malodorous discharge. The patient was previously in the hospital for chemotherapy and left AMA. The patient required close inpatient monitoring for the management of a breast wound in the setting of cancer. The requested admission was warranted based on Milliman Care Guidelines using the guideline of Medical Oncology, per treating provider. As per above, this was an old problem, and there were no new acute developments to justify an acute inpatient admission. Therefore, the request is denied and not medically necessary for this patient. 

"The tumor neglect phenomenon is of broad interest to the field of plastic and reconstructive surgery. Given the complex patient factors that contribute to the extreme state of disease progress upon presentation, all cases required extensive extirpative efforts with complex and challenging reconstructive solutions. Cases of extreme tumor neglect provide insight into the biopsychosocial underpinnings of this specific patient population and have implications for a further understanding of the potential immunoprotective effect of these large, longstanding, and often nonmetastatic tumors." (Block, et al., 2015)

"Discharge against medical advice (DAMA) is defined as when a patient chooses to leave a hospital before the healthcare team recommends discharge from the hospital [1]. With a significant and increasing prevalence of up to 12% of all hospital admissions, leaving against medical advice (AMA) affects both the patient and the healthcare provider [2,3]. This action leaves the patient with inadequately treated medical problems and increased risk for readmissions [1,4]. Even though no hospital is willing to allow DAMA due to its adverse consequences, this issue has become one of the most common problems in our current healthcare system. This problem affects both patients and physicians, but there may be solutions to this prevalent issue. In our study, we explore the risk factors, demographics, perspectives of patients and the healthcare system, consequences, prevention strategies, and other factors to tackle discharges AMA." (Albayati, et al., 2021)

The inpatient admission is not considered medically necessary for this patient.  The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. 

The patient had no acute issues, but a cosmetic problem that could have been managed as an outpatient, or on an observation level. The ER note sounds like chemotherapy had not actually at all yet been administered. It was also noted that surgery had seen the patient first and they recommended chemotherapy, due to acute bleeding.

The insurer's denial of coverage for inpatient admission is upheld. Medical necessity is not substantiated.