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202301-157430

2023

Empire Healthchoice Assurance Inc.

Indemnity

Cancer

Inpatient Hospital

Medical necessity

Overturned

Case Summary

Diagnosis: Acute lymphoblastic leukemia (ALL).
Treatment: Inpatient admission.

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

This is a patient, who has newly diagnosed acute lymphoblastic leukemia (ALL). The patient was pancytopenic and was found to have a fever of 100.7 degrees Fahrenheit (F). The patient was admitted to the hospital and was started on Inotuzumab ozogamicin in combination with low-intensity chemotherapy. The request is for the approval of the full hospital admission.

Validated scoring systems used to estimate the risk for medical complications include the Talcott rules, the Multinational Association for Supportive Care in Cancer (MASCC) score, and the Clinical Index of Stable Febrile Neutropenia (CISNE) score. These scoring systems assume the states of neutropenia and fever for a given patient and do not focus upon either the degree or duration of neutropenia as predictors of the likelihood of medical complications that require or prolong hospitalization.

High-risk patients are those who are expected to be severely neutropenic, absolute neutrophil count (ANC) less than (<) 500 for greater than (>) seven days and who have an MASCC score <21 or a CISNE score of three at the time of assessment. Intermediate CISNE scores (one or two) may require clinicians to judge the relative safety of outpatient oral therapy versus hospitalization for parenteral antibacterial therapy. Patients with neutropenic fever, who have ongoing comorbidities or evidence of significant hepatic or renal dysfunction are also considered to be high risk for medical complications, regardless of the duration of neutropenia.

Some experts have defined high-risk patients as those expected to have profound neutropenia (ANC 100) for > seven days, based on experience that such patients are the most likely to have life-threatening complications. However, formal studies to clearly differentiate between patients with an ANC <500 and 100 are lacking. For the purposes of this discourse, we will combine these groups. Profound prolonged neutropenia (ANC 100 expected to last >7 days) is most likely to occur in the pre-engraftment phase of hematopoietic cell transplantation (particularly allogeneic) and in patients undergoing induction chemotherapy for acute leukemia.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.

The medical necessity for a full hospital admission is substantiated.

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