Appeal type: Medical necessity
Decision: Upheld

Diagnosis Stage IV Lung Cancer with suspected metastasis

Treatment continued hospital stay

The insurer denied coverage for continued hospital stay

The denial is Upheld

The patient is an adult female. The medical records indicate the patient presented to the Emergency Department (ED) with stroke symptoms. She was shown to have lung cancer with suspected metastasis. 

The patient was seen for work up regarding stage IV lung cancer. On presentation to radiation oncology the patient had a reported deteriorating neurological function and was sent to the Emergency Room (ER) and was admitted. The patient was treated with steroids and Keppra and began radiation therapy. The patient was reported to be incontinent, fatigued and have right arm weakness but otherwise stable. The patient was working with physical/occupational therapy (OT/PT) and continued with radiation. The patient's blood sugars were high causing her to require insulin administration. The patient developed diarrhea due to contraction of Escherichia coli (E. coli) virus. The patient completed radiation therapy and was then discharged to a rehabilitation center. 

The patient did not require an inpatient stay which likely caused her hospital acquired E. Coli.      

The patient started radiation therapy and was clinically stable without deteriorating neurological findings. She could have been discharged to a skilled facility for PT/OT and continued steroids. As well, the patient could have received radiation therapy as an outpatient as patients do not need to complete whole brain radiation in an inpatient level. The patient was noted to be stable, so she could have been safely transferred to a lower level of care. Lastly, ongoing acute care was not warranted, and the prolonged acute care likely led to the development of hospital acquired Escherichia coli (E. coli) diarrhea. 

"According to the Centers for Medicare and Medicaid Services, a skilled nursing facility (SNF) is "a facility (which meets specific regulatory certification requirements) which primarily provides inpatient skilled nursing care and related services to patients who require medical, nursing, or rehabilitative services but does not provide the level of care or treatment available in a hospital."10 Individuals are discharged to a SNF when they no longer need care provided by a hospital but are unable to be sent home because they cannot get out of bed, move around, or use a wheelchair safely; have surgical wounds; or do not have adequate help at home. Like other long-term care facilities, SNFs provide assistance with activities of daily living, however SNFs also provide intravenous injections and physical therapy.10,11 These services are carried out by trained and licensed professionals (i.e., registered nurses and doctors). Personal care aides and CNAs are unable to perform these activities but assist with other duties. Other licensed professionals working at SNFs include physician assistants, nurse practitioners, physical therapists, occupational therapists, and speech language pathologists." (Heiks, C., & Sabine, N. 2022)

"Extraintestinal illness caused by E. coli results from a translocation of gut bacteria into other parts of the body or the environmental spread in hospitals and long-term care facilities. E. coli is the predominant gram-negative bacteria to cause extraintestinal illness in humans and can cause urinary tract infection, abdominal and pelvic infection, pneumonia, bacteremia, and meningitis, among others." (Mueller, M., & Tainter, C. R. 2023).                                                         

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 the continued hospital admission from at Memorial Sloan Kettering Cancer Center services is not substantiated.