Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Sepsis of unknown origin

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is overturned.

 
According to the documentation submitted, this is an adult with a history of testicular cancer, Crohn's disease, and mitral valve replacement (MVR). The patient presented to the emergency department (ED) with complaints a fever and elevated heart rate. During the admission the patient was followed by Hematology/Oncology and Infectious Disease (ID) services. Cultures had no growth. The patient had pancytopenia. The patient was treated with intravenous (IV) Vancomycin and IV Zosyn. The patient was transitioned to oral (PO) Augmentin and PO Ciprofloxacin. The patient was discharged. 

The insurer has denied coverage for the inpatient as not medically necessary. In a Final Adverse Determination letter, they stated that there were no severe problems warranting a full hospital admission. The requested admission is denied based on Milliman Care Guidelines using the guideline of Sepsis and Other Febrile Illness, without Focal Infection. 

In an appeal letter, the facility stated that the patient presented to the ED from the Oncologist's office with complaints of a fever and elevated heart rate. The patient was admitted with sepsis of unknown origin. ID consulted over the case. The patient was treated with IV fluids and IV antibiotics. The patient was discharged. The requested admission was warranted based on Milliman Care Guidelines 26th Edition using the guidelines of Sepsis and Other Febrile Illness, without Focal Infection ORG: M-160 (ISC), Chemotherapy ORG: M-87 (ISC), Fever: Common Complications and Conditions CCC: CCC-011 (ISC), and Medical Oncology GRG. 

The patient has past medical history significant for testicular cancer, status-post (s/p) left orchiectomy, Crohn's disease, s/p subtotal colectomy, and mitral valve replacement who presented to the emergency department with complaints of fever and tachycardia.  

Vitals on presentation included: Temperature 102.9 Fahrenheit, Blood Pressure (BP) 146/81, Pulse 146, Respiratory Rate 16, oxygen (O2) saturation 99%. Laboratory values were notable for the following: white blood cell count (WBC) 10.6, Hemoglobin (Hgb) 15.5, Hematocrit (Hct) 43, creatinine 0.69, glucose 108, lactate 1.64, and procalcitonin 1.28.

The patient was admitted for fevers being treated with adjuvant chemotherapy. Chest X-ray (CXR) was negative.  The patient was started empirically on antibiotics (vancomycin and Zosyn). During the hospital course, the patient became pancytopenic. A computed tomography (CT) scan of abdomen/pelvis showed no acute intra-abdominal pathology. The patient's fever improved, and the patient was hemodynamically stable. The patient was discharged to continue oral antibiotics as an outpatient.    

According to documentation, patient was admitted with fevers. The patient had a fever to 102.9, tachycardia (heart rate 146), and laboratory results showed mildly elevated WBC (10.6) and procalcitonin (1.28). Based on these findings in a risk immunocompromised patient with underlying malignancy and recent chemotherapy, hospital admission was medically necessary for administration of intravenous antibiotics and additional diagnostic evaluation. 

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient admission is substantiated.