Diagnosis: Breast Cancer.
Treatment: Inpatient admission.

The insurer denied the inpatient admission.
The denial is upheld.

The patient is a female with metastatic breast cancer. She presented initially to the hospital with bowel obstruction due to peritoneal carcinomatosis. She was placed on TPN (Total Parenteral Nutrition), had multiple attempts with IR (interventional radiology) surgery for relief. She was hospitalized and continued to decline and was on hydromorphone for pain control and was placed on PCA (patient-controlled analgesia). She was placed on comfort care. She clinically deteriorated and was placed on 1:1 while on comfort care. Her family eventually agreed to placement, and the patient was discharged to a hospice facility.

No, the Inpatient admission was not medically necessary.

This patient was eventually placed on comfort care per the hospital records. Acute care hospitalization is not necessary for comfort care/hospice level care. As such, the Inpatient admission was not medically necessary.

Yes, the health plan did act reasonably, with sounds medical judgment, and in the best interest of the patient.