Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Respiratory System-Pneumonia.
Treatment: Inpatient hospital stay.
The health plan denied the inpatient stay as not medically necessary. 
The reviewer has overturned in part the health  plan's determination.

The patient has adenoid cystic adenocarcinoma (managed with prior chemotherapy and radiation, complicated by severe epidural cord compression and diffuse leptomeningeal dissemination) who was sent from the clinic with shortness of breath (SOB) and hypoxemia. At admission, his peripheral capillary oxygen saturation (spo2) 88% on 100% non-rebreather (NRB) mask.  The arterial blood gas (ABG) 7.4/42/67/91%. COVID test was negative. A chest x-ray (CXR) was clear. The computed tomography pulmonary angiogram (CTPA) found no pulmonary embolism (PE) but did find bilateral basilar ground-glass opacities. He was diagnosed with hypoxemia, admitted, and changed to high-flow nasal cannula (HFNC) with improvement in spo2. Over the course of the first day, he was weaned down to 6 Liters (L) of oxygen (O2). By the next day he was saturating 95% on 6L; he appeared frail but no respiratory distress, had rhonchorous breath sounds, and cough noted to be weak. He was seen by hospital medicine who diagnosed acute hypoxemic respiratory failure due to aspiration pneumonia, recommended nothing by mouth (NPO) status and a swallow exam, ampicillin-sulbactam, and chest physical therapy (PT). Critical care medicine agreed with the medical plan and neurology who considered adding bevacizumab for spinal metastases. O2 was weaned over the course of the day to 2L. Unasyn was changed to Zosyn and azithromycin added. Progressive weakness was noted and felt to be from leptomeningeal metastatic disease. Dexamethasone 10 milligrams (mg) twice daily (BID) was recommended with plans for possible outpatient bevacizumab. He was saturating 95-97% on room air (RA) and remained NPO and was continued on intravenous (IV) antibiotics (Zosyn and azithromycin). His strength felt a bit better since starting steroids. Neurology recommended decreasing dexamethasone to 4 mg BID. He was seen by speech pathology who recommended a regular diet with strict aspiration precautions (apparently had been eating while lying flat at home). He continued to saturate well on RA, antibiotics and dexamethasone were continued. Neurology provided tapering recommendations for steroids, and he finished his course of antibiotics. The decision was made to initiate systemic treatment; given the difficulties with transportation, treatment was to be initiated while an inpatient. He was stable and received vinorelbine; he was awaiting transfer to a rehabilitation (rehab) facility. 
An inpatient admission was needed in part. He presented with cough, dyspnea, and hypoxemia, initially requiring high flow O2. This was felt to be due to aspiration pneumonia. His cough was weak and safe swallowing was in question. However, he was weaned off all supplemental O2. He was cleared by speech therapy to begin taking food and fluids by mouth. He remained on RA the rest of the admission and had no worsening of his respiratory status. His ability to consume a regular diet with aspiration precautions (a measure that can be done at a lower level of care) was confirmed, and he did well with this going forward. He did have ongoing help with secretion clearance (vest therapy), though this is also a technique that's usually used at a lower level of care and does not require inpatient status. As such, as he was on RA and was able to take (oral) POs, and did not worsen, he did not need ongoing inpatient admission for aspiration pneumonia. All subsequent treatments could have been done at a lower level of care. He did have diffuse weakness, but did not require inpatient only testing, monitoring, or treatment. He was seen by neurology who recommended dexamethasone and outpatient follow-up.