Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cancer.
Treatment: Long Term Acute Care Hospital (LTACH).
The insurer denied the Long Term Acute Care Hospital (LTACH).
The denial is overturned.

The patient is a female. The patient in this case was hospitalized in the Spring.  Her history is notable for widely metastatic poorly differentiated vulvar squamous cell carcinoma.  She had previously undergone anterior pelvic exenteration.  She was hospitalized after presenting with abdominal pain following the surgery done at another facility and being found to have a malignant small bowel obstruction.  During her hospitalization, she required multiple surgeries, including creation of an ileostomy and placement of a gastrostomy tube.  Her course has been complicated by septic shock and abscess formation.  She required multiple rounds of antibiotics and also drainage procedures.  She also had respiratory failure and required prolonged intubation and had a tracheostomy created.  In addition, she has required frequent transfusions and has had severe pain requiring high doses of narcotic pain medication.

At the time of discharge, the patient had multiple wounds requiring wound care and also required PCA (patient controlled analgesia) narcotic medication.  She was on TPN (Total Parenteral Nutrition), as she was unable to eat.  She required IV (intravenous) pain medication. Other medications were also being given IV (intravenous) due to ongoing bowel obstruction.

Based on the above considerations, it has been recommended that the patient be discharged to a long term acute care hospital.  A second letter indicated that despite searching, a suitable in-network facility could not be identified.  A referral was made to an in-network facility, but that facility would not accept this patient because she required the PCA (patient controlled analgesia) for pain control.

Yes, the long term acute care hospital admission is medically necessary.
This patient clearly requires treatment at a long term acute care hospital.  This is based on need for PCA (patient controlled analgesia) narcotic pain medication and also need for administration of other medications via the IV (intravenous) route.  Also supporting the need for LTACH (long term acute care hospital) admission is her wound care needs, TPN (Total Parenteral Nutrition) and her tracheostomy. She is clearly a complex medical patient who is at high risk for recurrent infection and other medical complications.  She also has required frequent transfusion.  Records indicate that no suitable in-network facility could be identified, and that the one facility identified in the initial denial letter refused this patient because she is on a PCA (patient controlled analgesia).  Given the need for LTACH (long term acute care hospital) admission and the lack of a suitable in-network facility, the proposed transfer to an out-of-network LTACH (long term acute care hospital) is medically necessary in this case.

The health plan initially denied this claim due to there being an in-network facility, which was appropriate at the time.  However, at this point, it has been shown that the in-network facility did not accept this patient.