Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission. The denial upheld.

This patient is a female who presented to the Emergency Department (ED) with complaints of a rash since three days prior and asthma as of a week prior.  Her vital signs were: Temperature (T) 98.8, Blood Pressure (BP) 105/73, Heart Rate (HR) 100, Respiratory Rate (RR) 19 and peripheral capillary oxygen saturation (SpO2) 97% on room air.  The impression was the patient had a drug induced rash from acetaminophen-butalbital, a new migraine medication and she also had an asthma exacerbation. The patient was given Benadryl, prednisone and a nebulizer treatment. The patient subsequently complained of intra oral lesions which appeared to be an aphthous ulcer in the lower right posterior gingiva.  Her lab work showed transaminitis with alanine aminotransferase which suggested liver involvement. The impression was that the patient had drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome.  The patient was admitted to the general medical floor for further treatment. Dermatology was consulted and recommended a prednisone taper.  The patient was clinically stable with instructions to follow up with a dermatology appointment.

"Severe cutaneous drug hypersensitivity reactions consist of different entities, some of which are life-threatening, such as Stevens-Johnson syndrome/toxic epidermal necrolysis, drug reaction with eosinophilia and systemic symptoms, acute generalized exanthematous pustulosis, generalized bullous fixed drug eruptions, serum sickness and serum sickness-like reaction and drug-induced vasculitis.  These reactions may have substantial morbidity and mortality. In the past years, successive studies have provided new evidence regarding the pathogenesis of some of these severe reactions and revealed that underlying mechanisms are highly variable.  Since these reactions have unique presentations and distinct pathomechanisms, the treatment methods and response rates might be different among various entities.  Although supportive and local therapies are sufficient in some of these reactions, targeted immunosuppressive treatments and even mechanistic therapies such as plasmapheresis may be required in severe ones.  However, there is still insufficient evidence to support the best treatment options for these patients since number of patients and large-scale studies are limited..."

The patient did not have all of these criteria and an observation status would have determined if there was any progression and if there was a need to admit to a more acute care setting. Therefore, the request for coverage cannot be approved.    

The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient.  The patient could have been placed in an observation status for 24 hours, had a dermatology consult while in observation status and the decision could have been made thereafter whether or not to admit.      

The inpatient admission was not considered medically necessary for this patient.  There was no hemodynamic, pulmonary, neurological or metabolic reason for the acute level of care.  There was no progression and laboratory studies that showed deterioration.  The patient's hemodynamic and pulmonary status maintained stability.  Twenty four hours in observation cystitis with a dermatology consult would have confirmed the patient's stability.                                                

Based on the above, the medical necessity for the inpatient admission is not substantiated.  The insurer's denial is upheld.