Diagnosis: Acetabulum Lesion.
Treatment: Full Hospital Admission.

The insurer denied coverage for full hospital admission.

The denial is overturned.

The patient is a female that had metastatic endometrial adenocarcinoma, diabetes, and hypertension. She presented to the emergency room (ER) with complaints of worsening right leg pain, which she could not control with previously prescribed oral opiates. Imaging revealed a right pelvic side wall mass and a new right acetabulum lesion. The patient was admitted to Gynecology service for an aggressive pain management regimen. She was given Gabapentin, Tylenol, and Morphine Sulfate (MS) Contin 15 milligram (mg). The patient reported that pain had improved. Orthopedic Surgery recommended further imaging and the tumor was found to have progressed into the right hip. Recommendations included no weight bearing on the right leg and trying to use a bedpan. Later, the pain was well controlled overnight with gabapentin, MS Contin 30 mg, and 4 mg of oral Dilaudid. Vital signs were stable. Radiation Oncology recommended no further episodes of palliative radiation to the right hip. Orthopedics recommended engaging in limited weight bearing activity with a walker. Physical Therapy evaluated the patient and noted that pain was a significant barrier to activity. Occupational Therapy would work with the patient 2-3 days a week. The patient was discharged. The health plan is denying the admission.

The Milliman criteria for in-patient admission of Pain Management states Hospital admission is needed for appropriate care of the patient because of 1 or more of the following: - Severe pain requiring acute inpatient management as indicated by 1 or more of the following: - Inpatient intravenous opioid treatment required as indicated by ALL of the following: - Pain insufficiently responsive to non-opioid analgesia (eg, NSAIDs [non-steroidal anti-inflammatory drugs]) - Alternative routes (eg, oral, transdermal, or submucosal) for opioid treatment not appropriate or not sufficient - Intravenous opioid treatment needed beyond observation care time frame (ie, conversion to alternative routes or medications not appropriate or not successful) - Pain control regimen for next level of care not established (eg, after observation care) as indicated by 1 or more of the following: - Sufficient pain control not achieved (eg, active adjustments to medications, dose, and route are ongoing).

This patient, with bone and liver metastases, met all of the admission criteria above.

Whitehouse, et al also advises careful titration and observation of the effectiveness of opiate administration to avoid complications.

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

The insurer's denial of coverage for the full hospital admission is reversed. Medical necessity is substantiated.