Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Infectious disease/Bacterial Infection
Treatment: Inpatient hospital
The insurer denied the inpatient hospital stay as not medically necessary 
The determination is upheld in whole

This case involves a patient with a history of hypertension, bleeding gastric ulcers, along with leukemia, currently on chemotherapy, who presented to the emergency department due to fevers. The patient reported a temperature of 101.3 F at home, denied any chest pain, abdominal pain, nausea, vomiting, or diarrhea. Upon arrival in the emergency department, the initial temperature was 100.9. The patient did not take any Tylenol at home. On subsequent recheck, it decreased down to 98.9. Laboratory data reveals stable electrolytes, stable renal function, and unremarkable LFTs. Lipase was elevated at 101. The white blood cell count is 3.1; hemoglobin is 7.5, and platelets are 69. A drug screen was presumptive positive for cannabis, negative for alcohol. Rapid influenza testing did not show any abnormalities. The urinalysis was also fairly unremarkable. A chest x-ray was done in the emergency department (ED) shows a right hilar mass, increased in size from the previous study.
Blood cultures were drawn in the ED, as well as lactic acid levels, and the patient was empirically started on Zosyn and vancomycin. Principal admitting diagnosis is systemic inflammatory response syndrome (SIRS) without a source of infection. The medical team also ordered an echocardiogram. The patient's leukopenia is attributed to the chemotherapeutic treatment for leukemia. The medical team accomplished a transfer to an outside hospital, where the patient's primary hematologist is located, as the patient is due to receive chemotherapy. Blood cultures remain negative.

The requested health service/treatment of inpatient stay is not medically necessary for this patient. The presentation can be accomplished under a lower level of care.
The patient presents with systemic inflammatory response syndrome, without an obvious source of infection. Complicating factors include leukemia and chemotherapy, which can make the patient appear to have SIRS, and possibly even sepsis. Hematologic malignancies are known to cause fevers and tachycardia. This patient is experiencing fevers but does not have clear evidence of profound neutropenia based on the laboratory data. There is no evidence of hemodynamic instability, hypoxemia, or altered mental status. There is no obvious source of focal infection such as pneumonia, or cellulitis or abscess formation. There is no evidence of renal or liver dysfunction. Lactic acid is normal, suggestive of no evidence of end-organ dysfunction. Based on the Multinational Association of Supportive Care in Cancer (MASCC) risk index, the patient scores 26, which predicts less than 5% risk of severe complication and a very low mortality rate of less than 1% and febrile neutropenic patients.
During the observation timeframe, the patient was appropriately monitored, and treated with IV antibiotics, while the determination is made, of progression to sepsis, versus improvement. In this case scenario, the patient improved. Therefore, admission to inpatient care is not necessary.