Appeal type: Medical necessity
Decision: Upheld

Diagnosis: COVID 19
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a male patient who was admitted to the hospital due to non-bloody diarrhea and suicidal ideation. The patient had a history of paraplegia caused by a spinal injury secondary to a gunshot wound many years before his presentation. The patient initially went to another hospital due to non-bloody watery diarrhea but was discharged home. He continued to experience diarrhea and subsequently presented to the emergency department due to feeling depressed and suicidal ideation.
Upon examination, the patient was alert and oriented, with no apparent distress. The patient denied any fever, headache, cough, shortness of breath (SOB), nausea, or abdominal pain. The patient reported taking Zoloft 200 milligrams (mg) daily for depression, with the last dose taken the day before admission. The patient has tried multiple antidepressants in the past with variable responses and was diagnosed with bipolar disorder the previous year. 
A physical exam revealed dry mucous membranes in the mouth, normal heart rate and rhythm, normal pulses, normal heart sounds, normal pulmonary effort and breath sounds, a soft abdomen, and slight tenderness in the left lower quadrant. The patient was paraplegic and had decreased sensation from the waist down due to a bullet wound in the spine.

The patient was admitted to the hospital and was placed on strict 1:1 observation and psychiatry was consulted urgently for evaluation. The patient was started on Lithium 300 milligrams (mg) twice daily (BID) and Ziprasidone 20 mg at bedtime due to the history of bipolar disorder, while Sertraline was tapered to 150 mg every day from 200 mg. The patient reported feeling better after a few days.
The patient was seen by a psychiatrist, who recommended discontinuing one-on-one observation and cleared the patient for discharge. The patient was advised to continue self-isolation and wear a mask in public due to COVID-19 positivity. The patient was also advised to follow up with the primary care physician within 1 week. At issue is the medical necessity of an inpatient stay.

An inpatient hospital admission was not medically necessary.
The indications for admission at the acute inpatient level of care for patients with COVID-19 infection may vary depending on the severity of the disease and the patient's underlying health conditions. In general, patients with moderate to severe COVID-19 symptoms, such as significant respiratory distress, hypoxemia (low oxygen saturation), or evidence of multiorgan dysfunction, may require hospitalization. Other factors that may necessitate acute inpatient care include the patient's age, comorbidities, and overall clinical status. Patients with advanced age, immunosuppression, chronic medical conditions (e.g., diabetes, heart disease, lung disease), or obesity may be at higher risk for severe COVID-19 illness and may require hospitalization, even with mild or moderate symptoms. Patients who are unable to maintain adequate oxygen saturation levels despite oxygen supplementation, or who require mechanical ventilation, may require admission to the intensive care unit. Additionally, patients who develop complications such as bacterial superinfection, acute respiratory distress syndrome, or thromboembolism may also require acute inpatient care. Ultimately, the decision to admit a patient with COVID-19 to the acute inpatient level of care is based on a careful assessment of the patient's clinical status, risk factors, and potential for disease progression.
In this particular case, the patient had no systemic or pulmonary manifestations of COVID-19 infection. Based on the progress notes, the next day after admission, the patient reported only one bowel movement. The patient remained afebrile and hemodynamically stable. Based on the same note, the patient had no suicidal ideations since he was admitted to the hospital.
Taking into consideration this information, there is not overwhelming evidence that either the severity of the patient's condition or the complexity of the services provided rose to the acute inpatient level of care.