Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pulmonary infiltrate

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld.

 
The patient was having trouble breathing and shortness of breath. There is a past medical history of polycystic ovary disease. She had a cough and yellow sputum for one month and there was a history of a 10-pound weight loss. One month prior to the admission she had undergone a tonsillectomy which was performed after she had received a 3-day course of steroids.

Four days prior to the admission she was complaining of sharp left sided chest pain that was pleuritic in nature. She was seen at the (ED) and she had a chest x-ray that noted a left sided pneumonia. A D-dimer blood test was obtained which was elevated. A Chest computed tomography (CT) scan was then performed which showed a possible 1.6-centimeter (cm) mass in the left lung. She was prescribed Augmentin with plans for a follow up imaging to assess for improvement.

The patient's chest pain and cough had improved on day 4 of a seven-day course of Augmentin but the mother was concerned and contacted the pediatrician for advice. The pediatrician referred the child to a Pediatric hematologist, who referred the child to the ED for admission to the hospital for a video-assisted thoracoscopic surgery (VATS) procedure to biopsy the lung. In the ED the chest x-ray was repeated which showed an alveolar opacity, lingular atelectasis and a left hilar lymph node. A Chest CT angiogram was then performed which showed a trace pleural effusion and a left sided 2.1 cm lymph node. A CT scan of the neck was then performed which showed some swelling of the jugular chain lymph nodes. The teenager was admitted to the hospital to prepare for the VATS procedure.

The Pediatric Surgeon was then contacted to consult on the case and he determined that the radiology studies were more consistent with an infection and that he did not recommend a biopsy be performed and so the VATS procedure was cancelled and the patient was discharged to complete the course of antibiotics.

The patient was previously diagnosed with a pulmonary infiltrate at the ED and her cough and chest pain were responding to treatment with Augmentin. She was on day 4 of a seven-day course of Augmentin. The decision to recommend admission to the hospital for additional chest imaging and to schedule a VATS lung biopsy was not appropriate and not consistent with the standard of care for an infiltrate and a lymph node detected by Chest CT scan. The patient could have been permitted to complete the prescribed antibiotic with follow up imaging arranged as an outpatient. The patient could have been seen for an outpatient consultation with the pediatric surgeon following completion of the antibiotic and the hospitalization would have been avoided.

Based upon review of the medical record the admission to the hospital was not medically necessary and the patient could have been safely discharged with continued treatment in the home and appropriate follow up.

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

The insurer's denial of coverage for the full hospital admission is upheld. Medical necessity is not substantiated.