Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lip Swelling

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

The patient is a patient with swollen lips after eating sushi. The patient was stable on room air (RA). The patient was admitted to the hospital. The request for the hospital stay is under review for medical necessity.

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. In consideration of the clinical standards of the plan, the information provided concerning the patient, the attending physician's recommendation, and applicable generally accepted practice guidelines developed by the federal government, national or professional medical societies, boards and associations, the health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The patient was hemodynamically stable and on room air. Care could have been safely provided at a lower level of care.      

A full hospital admission is not considered medically necessary for this patient. 

"Angioedema is defined by non-dependent, non-pitting edema that affects several different sites and is potentially life-threatening due to laryngeal edema. This narrative review provides emergency physicians with a focused overview of the evaluation and management of angioedema. Two primary forms include histamine-mediated and bradykinin-mediated angioedema. Histamine-mediated forms present similarly to anaphylaxis, while bradykinin-mediated angioedema presents with greater face and oropharyngeal involvement and higher risk of progression. Initial evaluation and management should focus on evaluation of the airway, followed by obtaining relevant historical features, including family history, medications, and prior episodes. Histamine-mediated angioedema should be treated with epinephrine intramuscularly, antihistaminergic medications, and steroids. These medications are not effective for bradykinin-mediated forms. Other medications include protein replacement, kallikrein inhibitor, and bradykinin receptor antagonists. Evidence is controversial concerning the efficacy of these medications in an acute episode, and airway management is the most important intervention when indicated. Airway intervention may require fiberoptic or video laryngoscopy, with preparation for cricothyrotomy. Disposition is dependent on patient's airway and respiratory status, as well as the sites involved" (Long, B. J., et al. 2019). 

"Allergy is described as an exaggerated response from the body's immune system to otherwise inert substances present in the environment. The usual symptoms are pruritus, flushing, rash, urticaria, swelling of the lips, tongue, and airway, (angioedema), nausea, vomiting, abdominal cramping, shortness of breath, wheezing and bronchospasm, stridor, syncope or collapse. This activity illustrates the etiology, pathophysiology, classification, and clinical symptomatology of allergy and highlights the role of health care providers in managing and educating the patients" (Dougherty, J. M., et al. 2023).

"Angioedema is non-pitting edema that involves subcutaneous and/or submucosal layers of tissue that affects the face, lips, neck, and extremities, oral cavity, larynx, and/or gut. It becomes life-threatening when it involves the larynx" (Memon, R. J., & Tiwari, V. 2023). 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for a full hospital admission is not substantiated.