Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dehydration.

Treatment: Inpatient Admission.

The insurer denied coverage for inpatient admission.

The denial is overturned.

The patient is a female with history of retinopathy of prematurity, patent ductus arteriosus repair, bronchopulmonary dysplasia, laryngomalacia, left vocal cord paresis, adenoid hypertrophy, and obstructive sleep apnea (OSA). The patient presented to the emergency department (ED) with throat pain status post tonsillectomy and adenoidectomy (T&A) and not eating or drinking for two days prior to admission. She developed worsening throat pain and refused a by mouth (PO) challenge twice. She was not swallowing saliva and had decreased urine output (UOP). A physical exam revealed oropharyngeal and tonsillar exudate and erythema with a temperature of 99.5. The patient was admitted for further management of dehydration with intravenous (IV) fluids, IV Tylenol, IV Toradol, IV Decadron, and close monitoring of input and output. Her condition improved and she was discharged home.

Based on a review of 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 not act reasonably and with sound medical judgment and in the best interest of the patient. Prolonged dehydration can lead to metabolic disturbances and serious complications in this patient with a complicated past medical history.      

The inpatient admission is considered medically necessary for this patient. The patient is a female, with a complicated past medical history true vocal cord (TVC) paralysis/laryngomalacia/OSA who became dehydrated after T&A and refused an oral challenge in the ED, with documented decreased UOP. This admission was medically necessary to prevent further complications from dehydration including IV fluids and IV pain control.

"The leading cause of morbidity following tonsillectomy is pain, subsequently leading to diminished oral intake and dehydration, dysphagia, and weight loss. It is important that caregivers are competent to monitor for signs of dehydration and continuously encourage their child to stay hydrated." (Bohr, C., & Shermetaro, C., 2022)

"Dehydration is the third major complication that occurs following tonsil and adenoid surgery. Intravenous fluids may be necessary in many affected patients. Ice chips or icy drinks may help relieve the throat pain while chewing gum or gummy candies help to relax pharyngeal muscles that are in spasm secondary to surgery. Oral or intravenous steroids may also help to reduce edema, improving swallowing. Because the opiate pain medications often cause nausea and vomiting, one should consider switching to a non-opiate pain medication or trying a dose of ondansetron to reduce nausea." (Wetmore R. F., 2017)

The health care plan did not act reasonably and with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for s inpatient is overturned. Medical Necessity is substantiated.