Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal Pain
Treatment: Inpatient Stay
The insurer denied the inpatient stay.
The health plan's determination is overturned.

The patient is a female with ovarian cancer receiving chemotherapy treatment with Carboplatin and Paclitaxel. She was admitted to the hospital with abdominal pain, shortness of breath, and knee pain with swelling. The patient was experiencing worsening exertional dyspnea for four days and orthopnea. She experienced pain radiating into the abdomen, back, and groin. She denied urinary frequency urgency or hematuria. Her vital signs showed a normal temperature, a heart rate of 126, and a blood pressure of 124/76. 

The computed tomography (CT) scan of the chest and abdomen pelvis showed atelectasis, thyroid nodule, and moderate ascites that have increased from previous imaging diverticulosis without diverticulitis. There was an increase in peritoneal tumor deposits.

The patient was admitted to the hospital and started on broad-spectrum antibiotics due to concern for infection, given the leukocytosis and tachycardia. The inflammatory markers C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) were obtained, as well as blood cultures. The medical team also checked a lower extremity doppler and planned to repeat the CT of the chest, as the initial read was inconclusive for pulmonary embolism (PE). However, the patient is chronically on Apixaban. Given the leukocytosis, they also worried about spontaneous bacterial peritonitis and consulted interventional radiology for a paracentesis.

Orthopedic surgery assessed the patient for right knee pain and performed right knee arthrocentesis. It showed 75,000 white and 3000 red blood cells with 93 percent (%) neutrophils and positive calcium pyrophosphate crystal deposition (CPPD) crystals. The orthopedic team felt the patient's knee pain is consistent with pseudogout. Later in the afternoon, the arthrocentesis was repeated, and the fluid analysis revealed significantly fewer leukocytes of 27.9 and no crystals. The conclusion reached was a low concern for a septic knee.

The interventional radiologist also assessed the patient, reviewed the CT scan, and felt the volume of ascites was not amenable to drainage. The patient was afebrile on this date, her heart rate was still elevated at 145, and her blood pressure was 104/73. The patient appeared to be in severe pain on the examination; however, when the attending assessed the patient, she appeared to be resting with no acute distress except for bilateral inguinal pain. The repeat chemistry showed stable values, and the white blood cell count decreased to 12.2.

This patient with ovarian carcinoma and peritoneal carcinomatosis presents with severe leukocytosis and systemic inflammatory response syndrome (SIRS) signs and is worrisome for severe sepsis. Multiple sources of potential sepsis were identified, including abdominal ascites, spontaneous bacterial peritonitis, right knee septic arthritis, and pneumonia. Based on the severity of the illness on presentation, the patient's risk factors of peritoneal carcinomatosis with ascites, and the immunocompromised state due to chemotherapy, it was reasonable to expect an inpatient level of care to be indicated for this presentation. 

The patient was given broad-spectrum antibiotics, and multispecialty consultations were obtained to evaluate for sources of infection. The patient underwent arthrocentesis times 2 to ensure there was no septic joint. The patient received broad-spectrum empiric antibiotics and subsequently switched to corticosteroids and pain management. The patient's pain in the knee and abdomen was intractable and required significant titration of pain medications. Therefore, inpatient criteria was satisfied for sepsis and intractable pain.