Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Mediastinal mass and altered mental status. 
Treatment: Full hospital admission. 
The insurer denied coverage for the full hospital admission. 
The denial is overturned. 
 
According to the medical records, the patient is an adult female who was admitted for altered mental status (AMS). She was found on imaging to have large mediastinal mass causing deviation of trachea/esophagus. She was transferred with no complaints of (c/o) chest pain, hoarseness, or shortness of breath (SOB). The status upgraded for airway observation given degree of tracheal deviation. The ears, nose and throat (ENT) evaluation showed a normal laryngoscopy. A left (L) thyroid mass was appreciated, and thyroid ultrasound (US) and fine needle aspiration (FNA) biopsy was recommended. Nuclear medicine scan/mammogram, and computed tomography (CT) guided biopsy was done. 

Although the patient has stable oxygenation and no airway edema, the size of the mass and location as well as risk of hemorrhage necessitated an expedient work up including imaging and biopsy. The risk of airway compromise was very possible until more information was obtained, and her status could be labeled stable. 

The patient was transferred for work up of extensive mediastinal mass originating from left thyroid lobe. Extensive imaging was needed as well as monitoring given tracheal deviation. Given unknown etiology of mass and potential for hemorrhage/airway obstruction acutely, an expedited work up was medically necessary. Once the patient was stabilized with appropriate outpatient follow up, she was discharged. 

"Mediastinal thyroid cancer is extremely rare, with few cases reported in the literature. Surgical excision of the malignant lesion, whenever possible, is the treatment of choice." (Lomelino Pinheiro, S. et al. 2021). 

"Untreated thyroid cancer can be locally invasive into the airway, esophagus, or other nearby neurovascular structures. Distant metastasis most commonly involves the lung, bone, and other soft tissue structures." (Lee, K. et al. 2023). 

"The mediastinum is an anatomical space between the lungs that houses the thymus, heart, large blood vessels, lymph nodes, nerves, and portions of the esophagus and trachea. It is bound anteriorly by the sternum, posteriorly by the thoracic vertebrae, superiorly by the thoracic inlet, inferiorly by the diaphragm, and laterally by the pericardial and mediastinal pleurae. It divides into anterior, middle, and posterior compartments. Mediastinal masses encompass a broad histopathological spectrum, ranging from benign to malignant. Fifty percent of mediastinal masses occur in the anterior compartment, the most common of which are thymoma, teratoma, thyroid goiter, and lymphoma. Middle mediastinal masses typically include congenital cysts, while posterior mediastinal masses are often neurogenic tumors, such as schwannomas. The focus of our discussion will center on anterior mediastinal masses." (Almeida, P. T. et al. 2023). 

Based on the above, the insurer's denial must be overturned. 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 a hospital admission is substantiated.