Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Anaplastic large cell lymphoma
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is partially overturned.

The patient is an adult male. The patient in this case has anaplastic large cell lymphoma. He had a mediastinal mass invading the supraclavicular region, right brachial plexus and 
encasing the brachiocephalic artery, right subclavian artery and right internal jugular vein. There was left mainstem bronchus involvement. The patient was sent from clinic to the Urgent Care Center with shortness of breath. He noted shortness of breath at rest and with minimal exertion. He had coughing when swallowing. He also complained of nine out ten (9/10) right shoulder pain at that time. Vital signs, physical exam and laboratory studies were without significant abnormal findings. He was admitted for expedited workup and treatment with combination chemotherapy treatment. While hospitalized, the patient underwent echocardiogram, positron emission tomography (PET) / computed tomography (CT) and core biopsy. He had a bone marrow biopsy. Chemotherapy was started with brentuximab, cyclophosphamide and doxorubicin. Following that, the patient had worsening shortness of breath and was found to have bilateral vocal cord paralysis. The following day the patient was intubated for airway protection and admitted to the intensive care unit. He had a computed tomography (CT) which showed extensive compression of the trachea and left mainstream bronchus by pathologic lymphadenopathy. Bronchoscopy with stent placement was performed two days later. The following day, the patient was extubated. He did well after that but was diagnosed with right upper extremity deep venous thrombosis. He was discharged three days later.

The admission for the initial two dates of service under review were medically necessary. However, the hospital dates of service at the end of the stay were not medically necessary.

This patient had newly diagnosed lymphoma with bulky mediastinal lymphadenopathy that was known to be compressing the trachea and left mainstream bronchus. It was also encasing many major blood vessels. He had severe pain and shortness of breath. While vital signs were not significantly abnormal and labs were also not significantly abnormal, he had vocal cord paralysis with dysphagia. He was at high risk for further airway compromise or large vessel compromise due to his clearly rapidly growing lymphoma. He required urgent evaluation and treatment, which was accomplished with inpatient admission. Outpatient evaluation and treatment would have taken a longer amount of time and would have exposed him to significant risk based on the location, bulk and rapid growth of this aggressive malignancy. Therefore, admission for expedited work-up was medically necessary. 
Following admission testing was done and chemotherapy treatment was given as documented above. The patient had worsening respiratory status, requiring intubation and bronchoscopy with stent placement. He was extubated and left the intensive care unit. During dates of service after the discharge from the intensive care unit, the patient was diagnosed with an upper extremity deep vein thrombosis for which he was treated with anticoagulation. However, otherwise there were no ongoing acute medical issues documented in the provided records. Based on provided records continued acute care inpatient admission was not medically necessary for the remainder of the dates of service under review.