These two case studies illustrate the impact the clinical care team can have on the outcome of a health plan's decision to cover a service or treatment. Remember, you are the oncology expert, not the health plan or their reviewers, and that expertise can make a profound difference in your patients' lives outside of the clinical setting.

In both of these case studies, without the assistance of the clinical care team, these patients' survival would have been in serious jeopardy. Your influence expands beyond the hospital or office, and your input in these situations can be critical.

Jean is a 74-year-old retired accountant with a long history of abdominal pain. She is also hypertensive and has osteoarthritis. Recently her abdominal pain increased to the extent that she could barely walk and she needed to lie down most of the time. After a particularly bad episode, Jean called 911 and was taken by ambulance to her local hospital.

Jean was admitted to the ER with pain and diffuse abdominal tenderness. She received additional pain medicine and IV fluids. Her primary care physician admitted her to the hospital and scheduled her for a CT scan of the thorax and a CT-guided abdominal biopsy. The CT scan of the thorax was normal, but the abdominal biopsy was consistent with a diagnosis of ovarian cancer.

Jean began chemotherapy while in the hospital. Instead of being discharged to home with nursing care, she was released into the custody of her daughter, who lived locally. Jean remained with her daughter until she completed chemotherapy and demonstrated that she could perform daily activities. At that point, she felt well enough to return home.

While at her daughter's house, Jean received notification from her insurer that they would cover her ambulance ride and her ER stay, but not her 2-day in-patient hospital stay. The health plan claimed that all the procedures she received during her hospital stay could have been done on an outpatient basis. The plan said Jean should have remained in the ER under observation until her pain was under control, and once stabilized she should have been discharged.

Appeal Strategy

Jean's daughter looked for help in her mother's appeal of the denial and found the Medical Care Ombudsman Program (MCOP). Subsequently, MCOP put together a panel of experts that included specialists in medical oncology and pain medicine. The panel was in complete accord that the inpatient stay was medically necessary and should be covered by the health plan.