Diagnosis: Neuropathic pain

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission. The denial was reversed.

This patient is a female with several medical conditions including breast cancer, leukemia, heart disease and arrhythmia. She was admitted to the hospital with severe pain in the right leg, radiating. She was admitted and received steroids, neurology consultation and transfusion. She required intravenous (IV) Dilaudid. She was treated for neuropathic pain and required Tacrolimus. She required ongoing Dilaudid IV. She received physical therapy (PT), occupation therapy and rehabilitative medicine consultations. Her pain gradually improved and she was discharged.

The admission was medically necessary for this patient. The medical record demonstrates several significant factors to substantiate admission and length of stay. This patient recently had undergone a bone marrow transplant. She recently was admitted to the hospital for severe pain. She had a history of AML (leukemia) and breast cancer and was on immunosuppressive therapy (Tacrolimus). Her condition had not improved since her last stay.

She reported severe pain requiring Morphine and intravenous Dilaudid. Due to her immunocompromised condition, it would be essential to define a pain generator. Her response to normal pain producing stimuli would be abnormal. She required diagnostic testing and monitoring. She was found to have anemia which required transfusion. She was evaluated by several sub specialists with their recommendations. She required steroids.

The combination of her underlying morbidities and current clinical condition thus required the admission and length of stay. The services provided (consultations, IV analgesia, IV steroid, monitoring for immunocompromised condition) could not have been completed on an outpatient basis. There were several extenuating circumstances to substantiate her admission and course of care.

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The inpatient hospital admission is considered medically necessary for this patient.

The carrier's denial of coverage for the inpatient hospital admission is reversed. The medical necessity is substantiated.