Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Throat infection

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

The patient is seeking coverage for inpatient admission due to throat infection.  The patient presented to the hospital complaining of sore throat and difficulty swallowing.  The symptoms started approximately 4 days prior while they were traveling.  The patient had presented to the emergency department (ED) and tested negative for mononucleosis and streptococcus.  Computed tomography (CT) showed pharyngitis and tonsillitis.  The patient was treated with amoxicillin and prednisone.  However, their symptoms continued to progress.  Vitals signs noted blood pressure of 92/54, pulse of 88, respirations of 28, temperature of 97.7 degrees Fahrenheit, and oxygen saturation of 99% (percent) on room air.  Laboratory results noted white blood cell (WBC) count of 8.0, red blood cell count of 4.42, hemoglobin of 14.3, creatinine of 0.78, glucose of 109, potassium of 3.9, and sodium of 135.  The patient was given a dose of Decadron 10 milligrams (mg) on 2 consecutive days with significant improvement in pain and swelling.  The physical exam noted erythematous tonsils that were 3+ with exudates.  There was cervical adenopathy.  The patient was continued on intravenous (IV) fluids which were weaned as their oral intake improved.  The patient was given intravenous Unasyn every 6 hours which was transitioned to Augmentin at discharge.  The patient was given a dose of 500 mg of ceftriaxone intravenous for presumptive treatment of Neisseria gonorrhea.  It was indicated that the patient may need tonsillar removal after the infection is resolved.  There was a plan for follow-up in 2 to 3 days with the primary care provider.  The patient was deemed appropriate for discharge.

It was argued by the hospital that the inpatient admission due to throat infection was medically necessary.  A summary of the patient's admission is detailed.  The patient presented to the emergency department with muffled voice, odynophagia, and sore throat.  The patient had previously been seen at another emergency department.  The patient had been taking amoxicillin and prednisone with worsening symptoms.  The patient reported difficulty swallowing the medication.  The patient was hypotensive at 92/54 and received 2 liters of intravenous fluid.  The patient was admitted to the hospital and received intravenous Unasyn every 6 hours and intravenous Decadron twice.  The patient also received intravenous fluids for greater than 24 hours.  

Per the cited guidelines, admission to the hospital for tonsillitis may be indicated when there is hemodynamic instability such as with hypotension that persist despite appropriate treatment, when there is airway obstruction or impending obstruction, when there is extension of infection into the deep tissues of the neck or superior mediastinum, when surgical drainage is needed that cannot be performed in observation care, or for thrombophlebitis of internal jugular vein.  In this case, the patient was admitted to the hospital due to suspected throat infection/tonsillitis with swelling.  While it is noted that the patient had hypotension, this responded to intravenous fluids.  The patient did not have hemodynamic instability such as with hypotension that persisted despite appropriate treatment, airway obstruction or impending obstruction, extension of infection into the deep tissues of the neck or superior mediastinum, a need for surgical drainage which could not be performed in observation care, or evidence of thrombophlebitis of internal jugular vein.  Thus, the patient's care could have been completed at a lower level such as observation.  

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 inpatient admission due to throat infection is not substantiated.