Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Dysphagia and hoarseness of voice.
Treatment:  Inpatient admission.

The insurer denied the inpatient admission.  The denial is upheld. 

The patient is a male with history of psoriasis, impetigo and allergy.  He presented to the ED (emergency department) with a one-week history of dysphagia and hoarseness of voice.  He had been seen in the ED (emergency department) a few days prior, and CT (computerized tomography) neck was done, which was normal with no evidence of any foreign body, and he was discharged home.  He presented again with complaints of hoarseness, drooling and ability to tolerate only small amounts of liquid.  He stated that he had food a few days prior to admission, and since then he has been choking on food.

The patient was seen by the ENT (otolaryngologist), and naso-laryngoscopy was performed, and no foreign body was found.  However, since the patient was drooling and not able to swallow, he was sent to the ED (emergency department) for further evaluation.  Since he suffers from allergies, he took Benadryl before coming to the hospital, but his symptoms worsened after taking it.

In the ED (emergency department), the patient was hemodynamically stable and afebrile.  He underwent CT (computerized tomography) chest that was normal except for calcified granuloma.  The ENT (otolaryngologist) was consulted for dysphagia and odynophagia, and on review of CT (computerized tomography) chest and neck, no foreign body was detected.  The GI (gastroenterologist) was contacted for consultation for the evaluation of dysphagia.

The patient was admitted for further evaluation and management of dysphagia.  The patient was able to swallow solid food after chewing the food well until it was smooth.  He was seen by the GI (gastroenterology) consultant, and EGD (esophagogastroduodenoscopy) was recommended.  The patient was NPO (nothing by mouth) after MN (midnight) for EGD (esophagogastroduodenoscopy).  However, for reasons not elucidated in the chart, the EGD (esophagogastroduodenoscopy) was not done. 

The patient underwent EGD (esophagogastroduodenoscopy), and no obstruction such as food impaction, foreign body or stricture was found.  The biopsies were done from the proximal and distal esophagus.  The biopsies of the esophagus revealed mild reflux esophagitis.  He was discharged home with an outpatient follow-up.

No, the Inpatient Admission for the management of this patient's condition was not medically necessary. 

The patient presented to the hospital with a one-week history of dysphagia, odynophagia and drooling.  He was seen in the ED (emergency department) two days prior, and a CT (computerized tomography) neck did not reveal any foreign body; therefore, he was discharged home.  He was seen by the ENT (otolaryngologist) as an outpatient, and the otolaryngoscopic evaluation was normal.  Due to the worsening of his symptoms, he was recommended by the ENT (otolaryngologist) to go the ED (emergency department) for evaluation.  He underwent X-ray of neck, and CT (computerized tomography) chest was done, which did not reveal any abnormality.  He was seen by ENT (otolaryngology) and GI (gastroenterology), and EGD (esophagogastroduodenoscopy) was recommended for the evaluation of dysphagia. 

The patient was admitted. He was able to eat solid food after chewing the food well to make it smooth.  For reasons that are not clear, the GI (gastroenterologist) did not perform the EGD (esophagogastroduodenoscopy) until the day after initially scheduled.  The EGD (esophagogastroduodenoscopy) revealed no evidence of any food impaction or obstruction.  Given this clinical scenario, the acute level care for this patient's condition was not appropriate and medically necessary.  As the patient was able to eat solid food after chewing it well, he could have been treated at a lower level of care with a soft diet or full liquid diet as tolerated with an outpatient follow up for EGD (esophagogastroduodenoscopy).  The inpatient stay from was not medically necessary.