Diagnosis: Type I cryoglobulinemic plasma cell dyscrasia.
Treatment: Inpatient admission.

The insurer denied coverage for an inpatient admission.
The denial is overturned.

This case involves a male who presented to the hospital with progressive weakness and the inability to safely transfer from his wheelchair to his bed along with increased urinary incontinence. He had a history of ischemic infarcts, progressive disability, dyslipidemia, monoclonal gammopathy of undetermined significance, shingles, vitamin B12 (cobalamin) deficiency, and potential mixed connective tissue disease. Records indicated that the patient was unable to move, was previously lucid, but became confused about his surroundings. The patient arrived via ambulance to the emergency department whereupon the patient was admitted with a need for urgent consultation from subspecialty fields of rheumatology, physical medicine rehabilitation, wound management, otology, and neurosurgery. He received advanced diagnostic noninvasive neuroimaging studies, diagnostic cerebral angiography, positron emission tomography/computed tomography, triple spinal fluid analysis, bone marrow biopsy, with extensive serological evaluation, and extensive physical/occupational, and speech therapy assessments. The patient was subsequently diagnosed with RNP (ribonucleoprotein) associated type I cryoglobulinemic plasma cell dyscrasia. He was placed on high-dose prednisone for 5 days, which required constant monitoring for potential adverse side effects, including adverse effects on the healing decubitus pressure ulcer noted on assessment. The patient subsequently discharged to an acute inpatient rehabilitation center.

The full hospital admission was considered medically necessary for this patient.

Literature has noted that plasma cell dyscrasia can lead to rare and aggressive plasma cell leukemia that comprises 1% of plasma cell dyscrasias. With the patient's multiple comorbidities, presenting condition, and lack of a confirmed diagnosis, the inpatient care was medically necessary given that the patient's condition was quickly deteriorating, and he required multiple studies, monitoring, and medical care that could not be obtained on an outpatient basis. He was not medically stable to discharge to a lower level of care based upon the provided information. Furthermore, given his administration of high-dose prednisone, this required constant monitoring for potential adverse effects, which had they occurred, would have needed immediate response with appropriate medical care available. Therefore, based upon the provided information, the prior determination should be overturned.

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

The insurer's denial of coverage for a full hospital is overturned. Medical Necessity is substantiated.