Appeal type: Medical necessity
Decision: Overturned

Diagnosis: MRSA pneumonia
Treatment: Inpatient Hospital Stay
The health plan denied the requested inpatient hospital stay as not medically necessary.
The health plan's determination is overturned.

The patient is a male with diabetes, hypertension, chronic obstructive pulmonary disease (COPD), renal cell carcinoma status post left partial nephrectomy, false vocal cord squamous cell carcinoma currently on Durvalumab with radiation to the larynx, now with recurrent disease and a right modified neck dissection along with a tracheostomy and a percutaneous endoscopic gastrostomy (PEG) who was admitted for thick secretions, hypoxia (oxygen saturation in 80's on home oxygen), shortness of breath and radiologic evidence of aspiration pneumonia. Notably, the patient has had multiple hospitalizations for respiratory failure and is not always compliant with a nothing by mouth (NPO) status, as he has been recommended. This episode, he reported he tried to eat some chocolates. Recently, the patient had a bronchoscopy that was positive for aspergillus, and he was on a course of Voriconazole with a prolonged steroid wean. The patient was admitted for sepsis related to a pneumonia. He had a positive methicillin-resistant staphylococcus aureus (MRSA) tracheal aspirate and completed a 14 day course of Zosyn  and a 10 day course of Vancomycin. He had a therapeutic bronchoscopy for copious secretions. The patient had thick secretions that required aggressive suctioning along with aggressive chest physical therapy through the date of discharge. He was intermittently hypoxic. Throughout the hospitalization, the patient experienced significant anxiety related to his symptoms of dyspnea and required a psychiatry consultation to adjust medications and relieve anxiety. The patient's secretion burden remained present but he was stable on a trach collar following completion of antibiotics and discharge planning was initiated (although the case management notes are not present, this is documented in the progress notes). The patient was continued on tube feeds and was strict NPO, but he was thought to be micro-aspirating. 

At issue is the medical necessity for the inpatient hospital stay.

I overturn, in whole, the health plan's determination of medical necessity.

The requested dates of service were medically necessary for the inpatient level of care.
The patient is medically complex with multiple comorbidities. This patient has a pneumonia likely from chronic aspiration secondary to non-compliance with NPO status and chronic aspiration from a tracheostomy. Aspiration and PEG placement are not uncommon following tracheostomy with laryngeal carcinoma (Anschuetz, et al, 2019). [1] The patient was found to have a tracheal aspirate positive for MRSA. MRSA pneumonia (of note a positive tracheal aspirate is equivalent to a bronchial wash in this case) has a high level of destruction of the lung and has a significantly slower resolution than other pathogens, despite appropriate antibiotics (Defres, et al, 2009). [2] The patient's course was consistent with a MRSA pneumonia, as the patient had significant secretion burden requiring aggressive chest physiotherapy. Discharge planning for this patient is quite difficult, as there are multiple pieces to consider (i.e. [that is] tracheostomy care, medication management, secretion burden, feeds through PEG tube, anxiety, multiple hospitalizations) and the patient's plan was to discharge home. Evidence of need for a strategy that supports the transition home for patients and families is important, as this can be a rough transition and success is impinged on an appropriate, well thought-out and communicated discharge plan (Nakarada-Kordic, et al, 2018). [3] Thus, from a clinical perspective, the patient is very complicated medically and continuing his admission to prepare for an appropriate and safe discharge was medically necessary for the declined dates in question. During this time period, the patient continued to require aggressive management for his secretions.