Appeal type: Medical necessity
Decision: Overturned

Lung Caner
Inpatient Hospital

The patient is a female with history of metastatic carcinoid tumor, with secondary neoplasm to the liver, lung, gastrointestinal tract as well as bones, who presented initially to the hospital with fever, cough, and shortness of breath. The patient was diagnosed with post-obstructive pneumonia, with cavitary lesions, located on the right side. The patient was treated with empiric antibiotics that included Levaquin as well as vancomycin, and underwent a right-sided chest tube placement, for pleural effusion. The pleural effusion was successfully drained and subsequently removed. A decision was made to transfer the patient to a designated cancer center, which specializes in carcinoid tumors, to be evaluated by oncology. The records for the hospitalization have been reviewed.
The patient arrived at the hospital complaining of diffuse pain to the chest, abdomen, back and hip areas. She was receiving intravenous (IV) Dilaudid and Percocet. She reported the fevers that were present during the hospitalization at the other hospital had subsided. She continued to complain of nausea and vomiting. Vital signs on admission included a temperature of 97.5, blood pressure 136/81, her pulse was 88 and the respirations were 18. The patient had an oxygen saturation of 97%. On exam, she was described as in no acute distress, alert and oriented x 3, lung sounds showed decreased breath sounds bilaterally, with crackles at the bases, right-sided more than left.
The patient did not have any rashes. The abdomen was soft without a rebound.
Laboratory studies on admission revealed a white blood cell count of 27.2, hemoglobin of 8.3, and platelets of 665,000. The blood urea nitrogen (BUN) and creatinine are normal, sodium is slightly low at 133. The anion gap is normal. Liver function tests are normal except for elevated alkaline phosphatase of 382.
A computed tomography (CT) scan of the chest with contrast was performed, which showed the progression of right upper lobe airspace disease with cavitation, finding concerning for post-obstructive cavitary pneumonia. There was also a concern for lymphangitic carcinomatosis. No pulmonary embolism (PE) was detected. There was also a new moderate right pleural effusion, which appeared loculated.
The primary diagnosis for admission was post-obstructive pneumonia in the setting of metastatic carcinoid tumors. The patient was continued on broad-spectrum antibiotics that included meropenem and vancomycin. Hematology oncology was asked to evaluate the patient, as well as an infectious disease specialist. Pulmonary medicine was also asked to evaluate the patient. The patient had been treated with lanreotide/telotristat for the carcinoid tumor, with plans to undergo radiation therapy to the spine. The pulmonary team felt that the patient had post-obstructive pneumonia, with possibly an endobronchial carcinoid component. They agreed with continuing broad-spectrum antibiotics. Given the recurrent fevers, they requested pan culturing the patient.  Interventional pulmonology was asked to evaluate as well, for possible intervention. Oxygen supplementation was continued. The patient was treated with vancomycin and meropenem, broad-spectrum antibiotics. Vancomycin levels were monitored. Over the coming days, the patient continued to experience temperatures up to 100.6, complaining of right-sided chest pain. Diminished breath sounds were documented, with increased dullness to percussion on an exam. Sodium levels fluctuated between 131 and 133. Alkaline phosphatase was elevated up to 446. Renal function remained stable. White blood cell count slowly trended down from 27,000-18,000.
The patient was afebrile, with a temperature (T)-max of 99.5 F, pulse was 83, and respirations were 18. Repeat laboratory studies showed a sodium of 131, the rest of the electrolytes were stable. White blood cell count had decreased down to 12.2, and the hemoglobin was 7.6. The patient developed some diarrhea, which was felt to be related to antibiotics, with low suspicion for C. difficile infection. The following day, the patient had a low-grade temperature again at 100 F, but the rest of the vital signs remained stable. The lung exam was unchanged. Broad-spectrum antibiotics were continued at this point. The dietitian evaluated the patient, and noted moderate malnutrition related to chronic disease, with 10% weight loss, and moderate muscle and fat loss.
Pulmonology reevaluated the patient and started transitioning the patient to oral Dilaudid for pain control, instead of IV Dilaudid. Sandostatin injections were continued per hematology. The next day the patient spiked a fever again of 38.1 Celsius. Repeat laboratory studies showed a normalization of the white blood cell counts down to 9.5, and improvement in the hemoglobin to 8.2 grams per deciliter (g/dL). Electrolytes and renal function remained stable. On this day, the patient described some vague urinary hesitancy and discomfort symptoms. Urinalysis was obtained.
The patient was eventually evaluated by interventional pulmonology, who felt that bronchoscopy would unlikely aid in relieving the obstruction. A repeat chest x-ray noted an 8 centimeter (cm) cavitary lesion in the right upper lobe, with multiple air lucencies. There was minimal blunting of the right costophrenic sulcus. The patient was noted to have decreased urine output, as well as complaints of bilateral lower extremity edema. Antibiotics were stopped, given that the patient completed a 9-day course of meropenem and vancomycin. The pulmonologist recommended monitoring the patient off of antibiotic therapy. The pedal edema was felt to be related to anasarca related to malnutrition as well as carcinoid heart disease. An echocardiogram was done, which had shown an ejection fraction of 61% with a dilated right atrium, moderate mitral regurgitation, and severe tricuspid regurgitation. The patient was noted to have mild to moderate pulmonary hypertension. Lasix 40 mg IV push was provided.
On the same day, the patient underwent radiation therapy, per oncology recommendations. The following day, her breathing improved, and so did her cough. The patient remained afebrile on this day. 2+ pitting edema continued. White blood cell count decreased down to 7.3. Radiation therapy was scheduled daily. Lasix was continued as well. The patient continued to be followed by a dietitian, who recommended Ensure supplements.
The Lasix dose was escalated to 40 mg IV twice daily. However, the patient lost IV access, and the dose was switched to oral equivalent at 80 mg twice daily.  The leg edema felt improved. The patient continued to have radiation therapy. Once IV access was reestablished, the Lasix was switched back to intravenous dosing. Renal function was monitored and was unchanged. The sodium levels did decrease down to 129, and the potassium increased to 5.4. A white blood cell count remained normal. The patient remained afebrile during this period of time.
The patient was also evaluated by the palliative care team for the management of pain. Outpatient appointments were scheduled.
The palliative team evaluated the patient and started her on long-acting as well as short-acting morphine for an established schedule. These were oral medications. The patient completed her last radiation treatment, was noted to have an improvement in the volume overload. At this point, the patient was safely discharged to home. The pitting edema was only 1+ on the day of discharge.
At issue is whether the above presentation warranted inpatient level of care and whether the transfer was necessary.

The health plan's determination is overturned.

In regard to the admission at an inpatient level of care, after reviewing the medical records, in their entirety, this reviewer concludes that inpatient hospitalization was necessary for this patient. This is a patient who presented to the hospital with complex post-obstructive pneumonia related to a carcinoid tumor, with daily fevers, severely elevated white blood cell count, requiring continuous reassessment by the pulmonary specialist, and intravenous antibiotics. The patient had an ongoing cavitary lesion, with loculations, as seen on multiple imaging studies. This type of pneumonia is typically managed in an inpatient setting and requires a multitude of resources to improve. The patient has a pneumonia severity index class IV, failure to respond to antibiotic therapy. This cannot be managed in a lower level of care setting. There is a real risk of the patient developing full obstructive symptoms, with the collapse of the respiratory system, and potentially requiring ventilatory support. In addition, the patient was experiencing daily fevers, despite antibiotic therapy, and severe pain that required management with intravenous narcotics.
In regard to the requested service of transfer to the current facility Mount Sinai Hospital, the requested health service/treatment of transfer, is indicated, as the patient was being transferred to a designated cancer center, which specializes in carcinoid tumors at Mount Sinai main hospital. The initial admission facility does not have such a designation, was unable to provide advanced tertiary care and therefore such transfer was indicated. The patient has a rare type of atypical carcinoid tumor, for which limited expertise exists outside of designated cancer centers/academic medical centers. In conclusion, the transfer was justified and medically necessary for this patient.