Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Non-Hodgkin Lymphoma, Unspecified.
Treatment:  Hospital Transfer and Admission.

The insurer denied the hospital transfer and admission.  The health plan's determination is upheld.

The patient is a female, who presented with a new finding of a large mediastinal mass and deep vein thrombosis within the distal left internal jugular vein extending into the left brachiocephalic and proximal subclavian veins. She was initially admitted to a hospital, then she was transferred to another facility and admitted to the pediatric intensive care unit (PICU), due to a high risk for pulmonary embolism, hemodynamic instability, and respiratory insufficiency related to her mass.  After admission to the PICU, she was treated with anticoagulation, and a cervical lymph node was biopsied, where the pathology was consistent with a large B-cell lymphoma.  She was treated with chemotherapy with Doxorubicin, Vincristine, and Etoposide by continuous infusion. She also required intravenous hydration from.  She was initially admitted to the first hospital but upon patient request was transferred to another cancer center.  

The cancer center she was transferred to was her preference based on previous history and knowledge of the facility, and comfort with their ability to care for her with a new diagnosis of cancer. 

The health plan, in its determination of medical necessity, did act reasonably, with sound medical judgment, and in the best interest of the patient.  

She was initially admitted to a facility with treatment options for both pediatric and adult patients with cancer. She was clinically stable, and there is no documentation to show that she needed additional treatments that could not be provided safely at the initial location. When comparing the 2 facilities, there is no significant difference in regard to treatment methods used for this type of cancer. There are both pediatric and medical oncologists at both facilities, and while the facility she was transferred to is considered a larger facility that specializes in cancer treatment, the patient was treated with a protocol that was also available at the initial facility. There is no documentation provided to show that there was a need for specialized services specific only to the facility she was transferred to. 

The patient's plan allows for transport between treating facilities when there is a need for service that is not available at the originating facility, such as specialty services, PICU care, surgery, or research protocols. None of these are clearly applicable in this case. Both facilities are children's oncology group members and offer similar treatment protocols. When looking at the location of the facilities compared to the patient's home of record, there is no clear difference in terms of distance and travel time. Records from the originating facility would need to clearly demonstrate that they were unable to provide appropriate treatment and care to this patient, requiring transfer to the gaining facility. This information has not been provided in this case.

According to the standards of care for pediatric oncology treatment centers, both the originating facility and the receiving facility have board-certified pediatric hematologists, oncologists and pediatric oncology nurses who are certified and knowledgeable. 

When looking at the location of the facilities compared to the patient's home of record, there is no clear difference in terms of distance and travel time. Records from the originating facility would need to clearly demonstrate that they were unable to provide appropriate treatment and care to this patient, requiring transfer to the gaining facility. This information has not been provided in this case.