Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Mast cell activation syndrome. 
Treatment: Inpatient admission. 

The insurer denied coverage for an inpatient admission. 

The denial is upheld. 

This case involves a female who had a past medical history significant for mast cell activation syndrome, asthma, and postural tachycardia syndrome. Records noted that the patient arrived at the emergency department claiming to have a rash and tongue numbness for 2 hours with reports of multiple allergies. She had taken 50 mg (milligrams) of Benadryl and 25 mg of prednisone 1 hour prior to arriving. During physical examination, the patient was tachycardic and appeared anxious. She had a fine papular rash on her forehead, neck, and chest.  Vital signs recorded a blood pressure reading of 144/84 and a pulse of 118.  Respirations were at 20 with temperature 98 and pulse oximetry 99% (percent). The patient left after feeling better with Benadryl. The patient was seen the following day with complaints of throat closing, hives, itching, and dizziness.  She took 50 mg of Benadryl and prednisone 25 mg 1 hour prior to her arrival. She claimed to have some vague abdominal discomfort since the onset of her symptoms but denies sensation of throat swelling or tongue swelling. The patient was anxious but denied chest pain, shortness of breath, or wheezing. On examination, the patient's blood pressure was stable with a pulse of 109. Oxygen saturation was 99% and her airway was patent with some very mild erythema and cobblestoning in the posterior oropharynx.  There were no signs of airway swelling or tongue swelling with a mild coarse quality to her voice. She had a resolving diffuse maculopapular, erythematous rash. The patient agreed to stay in the hospital for observation and potentially continue treatment. ENT (ear nose and throat) was telephoned and plan to scope the patient that night to get a baseline for her laryngeal state and possible edema. The patient was seen by ENT later that evening who determined that her upper airway was normal after endoscopy. The periodic hoarseness was known to her, and the physician stated the patient would be admitted for observation and closer watch. The patient was admitted that night. 

The Milliman Care Guidelines have noted that patients with a history of asthma may have clinical indications for admission to inpatient care when ventilatory assistance is needed, when their peak expiratory flow rate is less than 25% of predicted or personal best before treatment, when peak expiratory flow rate is less than 40% of predicted or personal best after treatment, when peak expiratory flow rate is between 40% and 60% of predicted or personal best after treatment and 1 more the following is noted to include that the patient has a history of asthma requiring intubation, hospitalization for asthma within the past year, current or recent use of oral corticosteroids for asthma, use of more than one canister of inhaled short acting beta-2 agonist in the past month, over there is an exacerbation due to allergic reaction to food.  In addition, admission for inpatient care may be needed for hypoxemia, when there is PaCO2 (partial pressure of carbon dioxide) elevation from baseline (or from normal if no previous measurement) of 2 mmHg (millimeters of mercury) (0.27 kPa (kilopascal)) or greater, or respiratory findings (for example dyspnea, accessory muscle use) that persist despite observation care for the same beta agonist response not sustained for at least 3 hours), when there is hemodynamic instability, altered mental status, or when there is radiographic evidence of complication requiring inpatient treatment to include tension pneumothorax. 

The health plan acted reasonably with sound medical judgment in the best interest of the patient. 

The insurer's denial of coverage for an inpatient is upheld. Medical Necessity is not substantiated.