Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of breath, Neck swelling
Treatment: Inpatient Hospital Stay.
The insurer denied Inpatient Hospital Stay.
The determination is upheld.

The patient has a past medical history of a pulmonary embolism/deep vein thrombosis, non-obstructive coronary artery disease, atrial fibrillation, gastroesophageal reflux disease, and obstructive sleep apnea (on continuous positive airway pressure, continuous positive airway pressure [CPAP]), and was recently admitted to the hospital for pharyngitis with marked narrowing requiring intubation. He presented with shortness of breath and uncontrollable drooling, associated with neck swelling over the prior two days. The patient reported a similar presentation about a month ago, following which he was discharged on home supplemental oxygen, steroids, and antibiotics. The patient felt well until two days before admission when the swelling worsened, attributing it to the cessation of medications. He complained of a muffled voice, swollen eyes (unusual for him), increased supplemental oxygen use at home, headaches, confusion, sinus pressure, intermittent red spots in his vision, increased hand swelling making it difficult to make a fist and tingling. The patient denied a fever, chills, chest pain, palpitations, nausea, vomiting, and diarrhea.
In the emergency department, the patient was hemodynamically stable. Imaging studies, including a computed tomography (CT) scan of the brain, a chest x-ray, and neck computed tomography (CT) scan, were negative for acute abnormalities, revealing marked adenoidal soft tissue enlargement causing nasopharyngeal narrowing and paranasal sinus disease. 
The patient was admitted to the hospital and received treatment with the intravenous antibiotic Unasyn and intravenous corticosteroid Decadron. Speech therapy recommended keeping the patient nothing by mouth (NPO) due to aspiration precautions, and he received supplemental oxygen during the hospital stay. An otolaryngologist performed a flexible fiber-optic nasolaryngoscopy, diagnosing minor laryngeal edema, gastroesophageal reflux disease (GERD), and obstructive sleep apnea. The ENT specialist recommended monitoring, suggesting chronic carbon dioxide retention with hypersomnolence.
The patient requested discharge. He was prescribed oral antibiotics and recommended follow-up with the primary care physician and ENT. At issue is the medical necessity of an inpatient stay.

A full hospital admission was not medically necessary for this patient. The patient had no signs of hemodynamic instability, significant airway obstruction or impending obstruction, evidence of infection in the deep tissues of the neck, or mediastinum. There was no need for any surgical intervention. It is not clear why the patient was placed on supplemental oxygen while his oxygen saturation was 92-94 percent (%) on room air at the time of the presentation. The endoscopic studies demonstrated only mild laryngeal edema.
The patient was assessed by an intensive care unit (ICU) physician who did not think that the patient required admission to the hospital due to the risk of airway obstruction.
Taking into consideration the information provided, a lower level of care was the most reasonable given the clinical symptoms for close monitoring of his respiratory status and the decision regarding continuation of treatment with corticosteroids and antibiotics.