Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Superior Vena Cava Thrombosis.

Treatment: Hospital admission.

The insurer denied coverage for hospital admission.

The denial is overturned.

This is an adult patient with a history of breast cancer. The patient had gradual onset of facial swelling. The patient's cardiologist ordered a computed tomography (CT) scan that showed a Superior Vena Cava (SVC) thrombosis with lymph node masses and compression of the SVC. The patient was directed to the emergency room (ER) and was admitted for anticoagulation therapy. Systemic anticoagulation is generally recommended to limit thrombus extension (in the absence of contraindications) until definitive treatment can be undertaken. SVC thrombosis is generally considered a life-threatening situation and acute hospitalization would be warranted for management. 

Drews, R.E. et al. (2022), " SVC syndrome results from any condition that leads to obstruction of blood flow through the SVC. Malignant obstruction can be caused by direct invasion of a tumor into the SVC. In addition, patients with malignancy have a higher risk of venous thrombosis related to indwelling venous devices (central venous catheter, pacemaker). Patients frequently complain of facial swelling or head fullness, which may be exacerbated by bending forward or lying down, or arm swelling. Swelling of the head and neck is visually striking but generally of little clinical consequence. The goals of management for malignant SVC syndrome are to alleviate symptoms and treat the underlying disease. Treatment of the underlying cause depends on the type of cancer, the extent of disease, and the overall prognosis, which is closely linked to histology and whether or not prior therapy has been administered. These factors all influence the choice of treatment. Evidence-based guidelines for management of SVC syndrome are not available. A general recommendation supporting radiation therapy (RT) or stent placement for symptomatic SVC syndrome has been made by both the National Comprehensive Cancer Network (NCCN; for patients with advanced malignancy and a life expectancy that is estimated in weeks to months) and the American College of Chest Physicians (ACCP) for lung cancer. Beyond this, specific recommendations for management are lacking. Current management guidelines stress the importance of accurate histologic diagnosis prior to starting tumor-directed therapy, and the urgent use of endovenous recanalization with stent placement, as necessary, in severely symptomatic patients to provide more rapid relief than can be achieved using chemotherapy and/or RT (radiation therapy)."

Seligson, M. T., & Surowiec, S. M. (2022), "Superior vena cava (SVC) syndrome is a collection of clinical signs and symptoms resulting from either partial or complete obstruction of blood flow through the SVC. This obstruction is most commonly a result of thrombus formation or tumor infiltration of the vessel wall. The superior vena cava is formed by the junction of the left and right innominate (brachiocephalic) veins and is tasked with returning blood from the head, neck, upper extremities, and torso back to the heart. Today, this syndrome is most commonly seen secondary to malignancy, although there has been a more recent rise in benign etiologies. The resulting venous congestion produces a clinical scenario relating to increased upper body venous pressures. The most common signs and symptoms include face or neck swelling, upper extremity swelling, dyspnea, cough, and dilated chest vein collaterals."      

Based on the above, the insurer's denial must be overturned. The health plan did not act reasonably, with sound medical judgment and in the best interest of the patient. The medical necessity for hospital admission is substantiated.