Diagnosis: Relapsed IgA Lambda Myeloma.
Treatment: Inpatient level of care services.

The insurer is denied coverage for inpatient level of care services. The denial is overturned.

This is a female patient history of IgG Lambda Myeloma and acute kidney failure. The patient had relapsed IgA Lambda myeloma, requiring radiation therapy from T8-S1 followed by CyBorD and RVD chemotherapy. The patient had an excellent response; however, she relapsed, evinced by positron emission tomography (PET) scanning. The patient was admitted for high dose chemotherapy and stem cell collection. She received infusion Cytoxan, Cisplatin and Etoposide with Intravenous therapy (IV) Decadron daily for four days. Each daily infusion took almost a day to be administered. The patient required constant intravenous (IV) hydration and close monitoring of blood counts and chemistries. The patient had a history of acute kidney failure. The patient developed severe distress and psychiatry assisted. When the patient's nausea and vomiting were under control on an oral regimen, the patient was discharged.

As per Kumar, et al (2020), "The NCCN Guidelines for Multiple Myeloma provide
recommendations for diagnosis, workup, treatment, follow-up, and supportive care for patients with monoclonal gammopathy of renal significance, solitary plasmacytoma, smoldering myeloma, and multiple myeloma." And according to Laubach et al. (2016), "The prognosis for patients multiple myeloma (MM) has improved substantially over the past decade with the development of new, more effective chemotherapeutic agents and regimens that possess a high level of anti-tumor activity. In spite of this important progress, however, nearly all MM patients ultimately relapse, even those who experience a complete response to initial therapy. Management of relapsed MM thus represents a vital aspect of the overall care for patients with MM and a critical area of ongoing scientific and clinical research."

Based on the review of the medical record and literature, inpatient level of care was medically necessary for this patient. The patient was getting high volume of intravenous (IV) fluids and daily infusions of three chemotherapy drugs over 22 hours. This was high dose chemotherapy.

The patient required constant monitoring of her blood counts and chemistries. The patient was at high risk for pancytopenia, renal failure and intractable nausea/vomiting. This treatment regimen is not typically done on an outpatient basis.

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.

Based on the above, the medical necessity for the inpatient level of care services is substantiated. The insurer's denial should be overturned.