Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hemoptysis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

The patient has lung cancer and presented to the emergency room (ER) with hemoptysis. This had been a chronic problem for some months. The patient was hemodynamically stable on admission. The patient was given Protonix and admitted. It was felt that an endovascular lesion from recurrent sarcoma in the lung was causing the bleeding. The patient remained in the hospital awaiting transfer to tertiary care.  The patient was then discharged to tertiary care.

The expectoration of blood that endangers life or the expectoration of large amounts of blood is associated with high morbidity and mortality. Prompt recognition and therapy are critical to successful management.  While efforts are ongoing to obtain useful clinical information from a brief history, examination, laboratory tests, and imaging, the clinician should ensure adequate oxygenation and ventilation, position the patient (lateral decubitus with suspected bleeding side down), ensure hemodynamic stability, obtain intravenous (IV) access, and perform initial measures to control the bleeding (e.g., treat any bleeding diathesis). In general, patients should be admitted to the intensive care unit for close monitoring when transfer is considered safe; early consultation of subspecialist services is prudent including pulmonary or interventional pulmonary, interventional radiology, thoracic surgery, and, if appropriate, radiation oncology and/or medical oncology. 

Per McGregor, B. A., et al., (2020), "Cancer patients frequently develop tumor and treatment-related complications, leading to diminished quality of life, shortened survival, and overutilization of emergency department and hospital services. Outpatient oncology treatment has potential to leave cancer patients unmonitored for long periods while at risk of clinical deterioration which has been exaggerated during the COVID-19 pandemic. Visits to cancer clinics and hospitals risk exposing immunocompromised patients to infectious complications."

"Cancer patients frequently experience local and systemic symptoms causally related to their malignancy. Local symptoms are due to direct complications of the primary tumor or metastases and can include pain, neurological deficits, respiratory symptoms (cough, shortness of breath, hemoptysis) and obstruction (bowel, biliary, airway). Systemic complications include cachexia, paraneoplastic syndromes, electrolyte abnormalities, metabolic alterations, and hematologic changes. These symptoms are a frequent cause of hospitalization" (McGregor, B. A., et al., 2020).

"Hemoptysis is appropriately defined as life-threatening hemoptysis that causes airway obstruction, respiratory failure, and/or hypotension. Patients with this condition die from asphyxiation, not hemorrhagic shock. Any patient who presents with life-threatening hemoptysis requires immediate treatment to secure the airway and stabilize hemodynamics. Early activation and coordinated response from a multidisciplinary team is critical" (Prey, B., et al., 2022). 

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.