Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypoxia

Treatment: Inpatient admission

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

This patient is a male child who was submerged under water when hit by a strong wave at the beach. He was brought onto the sand by a bystander who noted that the child was under water for some time and was not moving. The child was not responsive and not talking when evaluated on the sand. When he awoke, he was confused and was not able to recall the year. He was noted to be lethargic and to have some hypoxia when evaluated by Emergency Medical Services (EMS).  He was started on oxygen supplementation and an intravenous (IV) line was initiated to provide fluid resuscitation. There was no loss of consciousness reported. He was taken to the Emergency Room (ER) and upon arrival in the ER his pulse oximeter was 94%. He was treated with oxygen supplementation and an Advanced Trauma Life Support Protocol was initiated. He complained of tenderness over the neck and his thigh. When x-rays were normal, he was downgraded to a Level 2 trauma category and the decision was made to admit him to the hospital overnight for observation. The insurer has denied coverage for acute in-patient admission to the hospital.

Management of drowning victims can be divided into three phases: prehospital care, emergency department (ED) care, and inpatient care. Prehospital care and acute interventions - Rescue and immediate resuscitation by bystanders improves the outcome of drowning victims. The need for cardiopulmonary resuscitation (CPR) is determined as soon as possible without compromising the safety of the rescuer or delaying the removal of the victim from the water. Emergency department management- Prehospital resuscitative efforts should be continued and the airway secured as indicated. In the symptomatic patient, indications for intubation include the following: 1) Signs of neurologic deterioration or inability to protect the airway 2) Inability to maintain a partial pressure of oxygen [PaO2] above 60 mmHg, or oxygen saturation (SpO2) above 90 percent despite use of a high-flow oxygen-delivery system or noninvasive ventilation. Patient disposition-Most nonfatal drowning victims are hospitalized because of the severity of illness or concern for clinical deterioration. However, a review of 75 pediatric patients found that all who ultimately developed symptoms did so within seven hours of immersion.  

The patient was treated appropriately in the Emergency Room (ER) for an episode of near drowning with some hypoxia. When he was evaluated and had normal x-rays and EKG, he could have been observed in the ER and then released since he was not having any complications related to this near drowning episode. The decision to admit to the hospital was not consistent with the standard of care for treatment of a near drowning that is stable after a period of observation in the ER. 
The inpatient admission was not medically necessary for this patient. The insurer acted reasonably, with sound medical judgment, and in the patient's best interest. 

Based on the above, the medical necessity for the inpatient admission is not substantiated.  The insurer's denial is upheld.