Diagnosis: Fever, Metastatic pancreatic cancer.
Treatment: Full hospital admission.

The insurer denied coverage for the full hospital admission. The denial is overturned.

This is a male patient with a past medical history significant for metastatic pancreatic cancer, biliary obstruction, gout, esophagitis, and iron deficiency, who presented to the hospital for an elective endoscopic retrograde cholangiopancreatography (ERCP) for stent exchange. The patient's vital signs on hospital presentation included: temperature 100.5, blood pressure 101/59, pulse 98, respiratory rate 16, and oxygen saturation 98% on room air. The patient's laboratory values were notable for the following: white blood cell (WBC) count 26.6, hemoglobin (Hgb) 8.3, hematocrit (Hct) 24.8, creatinine 0.60, glucose 123, and sodium 120. He was empirically started on broad-spectrum intravenous (IV) antibiotics (i.e., ciprofloxacin and metronidazole) for possible cholangitis. The patient had an infectious work-up, including blood culture collection. He was treated with intravenous fluids (IVF) for hyponatremia that gradually improved. He remained afebrile and hemodynamically stable. The patient was discharged to continue outpatient management including follow-up with oncology.

According to medical records, the patient was admitted following an elective ERCP for concerns of infection. He had a fever of 100.5 followed by a fever of 101.4 F the next day. His laboratory results showed numerous abnormalities including an elevated WBC count, hyponatremia, anemia, and elevated liver function tests. Considering these clinical findings in a high-risk, immunocompromised patient with metastatic cancer following a procedure, the literature review supports that inpatient admission was medically necessary for IV antibiotics and additional diagnostic evaluation.

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

The carrier's denial of coverage for the full hospital admission should be overturned. The medical necessity is substantiated.