Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Vocal Cord Dysfunction

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.

The denial is overturned.

The patient is a female child with a history of asthma and recent laryngeal cleft repair. She presented to the emergency room (ER) with complaints of shortness of breath (SOB) after trying an advancing diet. The parents gave her some albuterol with some improvement noted and brought her to ER. In the ER the patient was in stable condition. Otolaryngology performed a scope and there were normal postoperative findings. The rapid viral panel (RVP) and COVID (coronavirus) testing were negative. She was admitted to the medical surgical unit for pulse oximetry monitoring. Otolaryngology felt that findings were consistent with vocal cord dysfunction. They recommended regular solids with honey thickened consistency liquids and speech pathology evaluated the patient. They educated the patient's mother on vocal cord dysfunction and rescue breathing techniques. Outpatient speech therapy was recommended. The patient continued to tolerate a regular diet with adequate output. She was discharged with instructions to follow up with the physician within one to two days of discharge.

Regarding laryngeal cleft repair, Harris, V.C., et al write, "In this cohort, respiratory events after type 1 laryngeal cleft repair occurred early in the postoperative period, in children with cardiac and pulmonary comorbidities. This suggests postoperative admission may only be necessary for a select group of patients undergoing type 1 cleft repair." 

In another study, Martha, V. V., et al write that, "A total of 1033 patients were included. Based on 415 cases for whom sufficient classification data were available, the [predominant] symptom for patients with type I [1], III [3], and IV [4 ] clefts is swallowing dysfunction, while the predominant symptoms for patients with type II clefts are stridor and aspiration. A wide variety of comorbidities involving several major organs has been reported with laryngeal clefts, which tend to impact clinical outcomes negatively. Approximately 19% [percent] of type I clefts have been treated conservatively successfully, but the majority was treated surgically. Most studies that used injection laryngoplasty for type I clefts reported highly successful repairs without complications or delays in additional procedures. Ninety-eight percent [of] all type II clefts were treated with endoscopic repair; 87% of patients with type III clefts received endoscopic repair; and 66% of patients with type IV clefts underwent open surgery. Approximately 62% of resolved cases were reported within 12 months, while 50.87% of failed cases were reported within 6 weeks." 

Finally, per Osborn, A. J., et al "Despite a high rate of surgical success, a substantial minority of children have persistent swallowing dysfunction after laryngeal cleft repair. Swallowing dysfunction after repair is multifactorial and arises from concomitant neurologic, anatomic, or other comorbidities that contribute to oropharyngeal and pharyngeal dysphagia." 

This patient was in the immediate postoperative period from airway surgery with congenital abnormalities and presented for SOB unrelieved by inhalers. Examination including laryngoscopy was consistent with vocal cord dysfunction. She was admitted for continuous oximetry monitoring and discharged when stable. She was not stable enough to be observed in a home setting. Based on the submitted documentation, the inpatient hospital admission is considered medically necessary for this patient.

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

The insurer's denial of coverage for the inpatient hospital admission is overturned. Medical necessity is substantiated.