Appeal type: Medical necessity
Decision: Upheld

Diagnosis: invasive squamous cell carcinoma of the oral tongue.
Treatment: Inpatient admission.
The insurer denied coverage for inpatient admission.
The denial is upheld.

This is an adult male patient with a history of malignant neoplasm of dorsal surface of tongue, dysphagia, adult failure to thrive, poor dentition, tobacco use, alcohol dependence, and atherosclerotic heart disease. The patient was transferred to the emergency department (ED) from an outside hospital for higher management of care for a tongue mass. A biopsy determined the mass was clinical stage IV invasive squamous cell carcinoma of the oral tongue, measuring 5.0 x 2.5 x 3.4 centimeters (cm), with greater than 2.0 cm depth of invasion, with possible invasion of adjacent oral mucosa on the neck soft tissue. The ENT (Ear, Nose and Throat) evaluation determined the mass was inoperable. The patient was admitted for further management of care for failure to thrive and percutaneous endoscopic gastrostomy (PEG) placement in preparation for cancer treatment. ENT, Oncology, Gastrointestinal (GI), Occupational Therapy (OT), and Physical Therapy (PT) services were consulted. Due to poor dentition, 14 teeth were extracted at the dental clinic. 

The coordination of services for management of head and neck cancer is commonly done on an outpatient basis. If social problems interfere, a nursing home placement is appropriate for the coordination of services. Hospitalization may become necessary to handle complications of chemotherapy and radiation but is not medically necessary to establish and begin treatment. As such, the inpatient hospital services are not considered medically necessary for this patient.

Per Ling, D. C., et al., (2015), "We found that 34.7% of patients experienced a chemoradiation toxicity-related hospitalization during or shortly after treatment. Prior pulmonary disease, diabetes, and increasing prescribed radiation dose were associated with increased hospital stays."

Per Terzo, L., et al., (2017), "Head and neck cancer (HNC) treatments cause severe toxicities, leading to high rates of ED visits and unplanned hospital admissions (UHAs)."

Per Townsend, M., Kallogjeri, D., Scott-Wittenborn, N., Gerull, K., Jansen, S., & Nussenbaum, B. (2017), "Contemporary management of head and neck cancer involves professionals from multiple specializations. Streamlined care that reduces delays yet allows for comprehensive evaluation is needed. To evaluate a single-day, single-appointment, multidisciplinary head, and neck clinic model for reduction in treatment delay and comprehensiveness of care. A retrospective cohort analysis was conducted, of outpatients at a single, academic medical center. All eligible outpatients seen in either the multiple-appointment, traditional clinic (n=73) or the single-day multidisciplinary clinic (MDC) (n=68) were included. Patients with new squamous cell carcinoma of the oropharynx, hypopharynx, sinonasal tract, and larynx, along with any mucosal site recurrence were eligible for the study. Coordination of the management of head and neck cancer is complex. Treatment is time sensitive, and frequently clinician resources are limited. This MDC model was associated with improved efficiency and completeness of care."     
                                                    
Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for inpatient admission is not substantiated.