Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pleural effusion, metastatic disease
Treatment: Inpatient hospital admission 
The insurer is denied coverage for inpatient hospital admission.
The denial is upheld. 

This female patient has a history of breast cancer status post mastectomy in 2014.  The patient received chemotherapy and radiation therapy (RT) in 2015.  The patient presented to the Emergency Department (ED) with complaints of intermittent chest pain for two weeks and sharp vertebral / back pain that had worsened since the night prior to ED presentation. The patient also reported an unintentional weight loss of 20 pounds over the past four months. In the ED, the patient's vital signs were: temperature (T) 98.5 F, heart rate (HR) 118, respiratory rate (RR) 20, blood pressure (BP) 111/77, and oxygen (O2) saturation 98 % on room air (RA). The patient's lung exam was clear, and her cardiovascular exam was unremarkable. The patient was noted to be alert and oriented, with non-focal neurological exam. The patient's lab results showed white blood cell (WBC) count of 5.7K and hemoglobin of 9.9; the patient's electrolytes, BUN/ Creatinine were all within normal limits (WNL). The patient's electrocardiogram (EKG) showed no evidence of acute ischemia. The patient's procalcitonin was low at 0.08. The patient's chest x-ray showed left basal opacity possibly related to pleural effusion with underlying atelectasis/infiltrate. The patient's computed tomography angiogram (CTA) revealed bilateral effusions, left-side greater than the right-side, and with multiple lung nodules. The patient had compression fracture of T6-T7 with sclerosis in thoracic spine and sternum. This patient's clinical presentation was consistent with metastatic disease. The patient's computed tomography (CT) scan of the abdomen revealed a 3 cm hypodense lesion that was suspicious for metastatic disease. The patient was admitted to rule out acute coronary syndrome (ACS). The patient's bilateral effusions and other radiologic findings were suggestive of metastatic breast cancer. The patient's serial electrocardiograms (EKG) and troponins ruled out myocardial infarction (MI).  The patient's echocardiogram revealed normal ejection fraction (EF) of 60%, with normal right ventricular function.  The patient was seen by pulmonary for possible thoracentesis; however, no suitable pocket was found under ultrasound so the thoracentesis procedure was deferred.  The patient was scheduled to follow up with interventional radiology for outpatient liver biopsy to rule out metastatic disease. The day prior to discharge, the patient had a fever of 102.8 for which she was treated with intravenous antibiotics for possible pneumonia. 

Based on the review of the medical record, the patient remained stable after admission.  Although the patient spiked a fever, there was not clear indication that this patient had pneumonia. The patient was hemodynamically stable and was tolerating oral intake well. The patient was not hypoxic and did not require supplemental oxygenation. 

The patient's etiology of possible MI could have been ruled out with serial cardiac enzymes and EKGs at the observational level of care. No inpatient procedure was done during this patient's hospitalization. Based on the review of the medical record and literature, the patient could have been discharged home on oral antibiotics with close follow-up in an outpatient setting after a period of observation and diagnostic workup. 

The health plan acted reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the inpatient hospital admission should be upheld.  The medical necessity is not substantiated.