Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pleural Effusion. 
Treatment: Inpatient Admission. 

The insurer denied coverage for inpatient admission.  The denial is overturned. 

According to the documentation submitted, this is an adult with a history of chronic myeloid leukemia (CML). The patient presented to the emergency room (ER) with complaints of difficulty breathing. A chest x-ray (CXR) revealed pneumonia. The patient was admitted for care. A thoracocentesis was done and 1600 milliliters (ml) of fluid were removed. The patient's condition improved after treatment. The patient was discharged. 

The insurer has denied coverage for the inpatient admission as not medically necessary. In a Final Adverse Determination letter, they stated that the patient presented to the ER with possible pneumonia. The patient was on oral chemotherapy. A thoracentesis was done. The patient could have been treated at the observational level. The requested admission is denied based on the policy United Healthcare Community Plan Medical Policy Hospital Services: Observation and Inpatient Policy Number: CS356.A Effective Date: December 1, 2022; and InterQual October 2022 Release, Level of Care: Acute Adult General Medical. 

The patient is an adult female with a history of chronic myeloid leukemia (CML) on oral Chemotherapy. The patient presented to the emergency room (ER) with complaints of worsening shortness of breath (SOB). The patient had been seen by a physician as a Telehealth visit a week earlier and was prescribed Doxycycline. The patient did not improve, so the patient went to Urgent care where a chest x-ray (CXR) was done, and the patient was sent to the ER. 

In the ER the patient was afebrile, heart rate 110, respirations 18, blood pressure 172/84, oxygen saturation 97% on room air. Repeat CXR was done, which revealed bilateral lower lobe opacities/ effusion. Computed tomography angiography (CTA) was done and revealed large bilateral effusions with underlying compressive atelectasis. White blood cell count was 7.4. 

The patient was admitted to the hospital for further evaluation and management. The patient was given intravenous (IV) Lasix. The patient seen by Pulmonary, Cardiology and Hematology Oncology. Pulmonary felt that the pleural effusions may be related to Chemotherapy- Dasatinib. 

The plan was for a diagnostic and therapeutic thoracentesis. The patient had a near syncopal episode, possibly vasovagal. The patient underwent thoracentesis and 1600 milliliters (ml) of fluid was removed. The fluid was a lymphocyte predominant exudate. The patient felt better after thoracentesis and was ambulating without oxygen. The patient remained stable after admission, and the fluid was determined to be from their medication. The patient was subsequently discharged home the next day with outpatient follow-up. 

Given that this patient was immunocompromised (CML on Chemotherapy), had not responded to outpatient treatment with antibiotics, and CXR revealed large pleural effusions (of unknown etiology) with compressive atelectasis of lungs, it was appropriate to admit this patient for diagnostic and therapeutic thoracentesis and further management. 

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.  

The medical necessity for the inpatient admission is substantiated.