Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Esophageal Cancer, Weakness
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

The patient initially presented to the emergency department with concerns for weakness and worsening pain in the head. Pertinent history included recent hospitalization with discharge followed by palliative radiation for esophageal cancer. Additional history included coronary artery disease, ischemic cardiomyopathy, hypertension, atrial fibrillation, cardiac pacemaker placement, and diabetes mellitus. Initial vital signs revealed a temperature of 97.8 degrees Fahrenheit (F), heart rate (HR) 43, blood pressure (BP) 104/71, respiratory rate (RR) 16, and peripheral capillary oxygen saturation (SpO2) 97% on room air. Initial examination documented the patient as alert and oriented. Initial laboratory testing revealed a white blood cell count (WBC) of 13.3, hemoglobin (Hgb) 15.7, platelets (Plt) 228, blood urea nitrogen (BUN) 34, creatinine (Cr) 0.7, sodium (Na) 129, potassium (K) 4.1, glucose (Glu) 141, lactic acid 1.6, total bilirubin (Tbil) 1.0, alkaline phosphatase (ALP) 97. A chest radiograph was unremarkable. The patient was admitted to the hospital with an impression of headache, severe back pain, uncontrolled pain, poor oral intake, and metastatic esophageal cancer. The treatment plan included continuation of fentanyl patch, increase of Dilaudid from 1 milligram (mg) every hour, and dexamethasone. The pain was improved with an analgesic regimen. His appetite remained poor. Magnetic resonance imaging (MRI) of the cervical (C) -spine and MRI of the brain appeared to show possible metastatic lesions. An oncology consultation was obtained whom had an impression of metastatic esophageal adenocarcinoma with extensive bone, paraspinal, and probable chest wall soft tissue involvement. After a long discussion with patient and family, comfort care was pursued. The Fentanyl patch dosage was increased, dexamethasone continued, and oral Roxanol every hour was attempted. Later in the evening, he experienced a "pain crisis" which took 2 hours of as needed intravenous analgesia to get it under control. The patient and family requested to be discharged to home for comfort care on Hospice.
At issue is the medical necessity of an inpatient stay.

Yes. Based on the clinical documentation provided, evidence based literature and standards of care, acute inpatient level of care was indicated as medically necessary for the entire admission.
Short et al. note esophageal cancer has a poor prognosis and high mortality rate, with an estimated 16,910 new cases and 15,910 deaths projected in 2016 in the United States. Adenocarcinoma is the predominant esophageal cancer in developed nations, and important risk factors include chronic gastroesophageal reflux disease, obesity, and smoking. Dysphagia alone or with unintentional weight loss is the most common presenting symptom, although esophageal cancer is often asymptomatic in early stages. Localized tumors can be treated with endoscopic mucosal resection, whereas regional tumors are treated with esophagectomy, neoadjuvant chemotherapy, chemoradiotherapy, or a combination of modalities. Nonresectable tumors or tumors with distant metastases are treated with palliative interventions.[1]
In this particular situation, the patient had a history of esophageal adenocarcinoma with extensive metastases who presented with intractable pain, minimal oral intake, and significant weight loss. The treatment plan included a Fentanyl patch, intravenous opiates, and oral opiates. After a thorough discussion and with oncology assistance, the patient elected for comfort care measures at home once pain was controlled. Despite the aforementioned analgesic regimen, the patient had a "pain crisis" requiring additional intravenous opiates to get the pain under control. The clinical indications for admission to inpatient care were met. The patient had severe pain requiring acute inpatient management, inability to maintain adequate oral hydration, and possible severe acute radiation esophagitis. Continued opiate titration for end of life was needed.[2][3]