Appeal type: Medical necessity
Decision: Upheld

Respiratory System
Inpatient Hospital

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

The patient presented with a chief complaint of chest pain. Per the patient, he was sitting in class on the day of presentation after lunch when he began to experience severe mid-sternal chest pain and feeling as if his throat was swelling. He was able to stay in school and did not visit his school health provider. When he went home, he took an aspirin with no relief so he presented to the emergency room (ER).
He had been in his usual state of health with mild rhinorrhea for about 2 days but denied any cough or vomiting. He has no significant past medical history and denied a history of asthma. He denied any drug use. There was no history of recent trauma and no recent vigorous activity or exercise. On presentation to the ER he was found to have pneumomediastinum on a chest x-ray (CXR) which was confirmed by a computed tomography (CT) scan. He had a normal electrocardiogram (EKG). He was given a dose of Ceftriaxone. He did not receive any medications for pain control. He was transferred to the accepting hospital for further management.
Upon arrival to the accepting hospital, he complained of pain in his lower throat/upper chest as well. He stated that his pain was worse when he coughed or burped or took a deep inspiration. He also reported pain with lying on his left side. Vital signs were stable with blood pressure (BP) 103/61, heart rate (HR) 69, temperature 98.1 degrees Fahrenheit, respiratory rate (RR) 17, and oxygen saturation (O2 sat) 100% on room air. He was found to be in no acute distress and was speaking in full sentences without pain to palpation of the midsternum. An electrocardiogram (EKG) was within normal limits (WNL). A chest x-ray (CXR) showed pneumomediastinum; a CT scan confirmed this with subcutaneous emphysema along the left clavicle. Labs were drawn and were all normal. The physical exam was normal. The assessment at the time of admission stated given that the patient was stable with no significant symptoms, the patient did not need specific interventions at that time. If he became symptomatic he could receive high concentration oxygen therapy. He was admitted to provide analgesia, consult cardiothoracic surgery and repeat imaging to monitor for any progression or improvement. The cardiothoracic surgery team evaluated the patient and recommended supportive care. He received Motrin as needed (PRN) for pain. He had increased burping and some pain with burping but overall the pain had resolved from ER. A repeat x-ray (XR) was performed which was stable from first XR. The patient remained hemodynamically stable with good pain control and was stable for discharge as per the cardiothoracic surgery and pediatric hospital medicine teams. At the time of discharge, he denied any chest pain. He was instructed to follow up with the primary medical doctor (PMD) as an outpatient and to return to the ER if pain recurred.
At issue is whether the inpatient stay was medically necessary.
The inpatient stay was not medically necessary for this patient. This patient presented with chest pain that was found to be a spontaneous pneumomediastinum after work up was completed. He did not have any know underlying comorbidities or medical issues. He was stable at the time of presentation as well as at the time of admission. His vital signs and laboratory studies were unremarkable. Although pneumomediastinum is a rare entity in the pediatric population, there is literature that provides guidance on management. The mainstay of management is rest and analgesics. If moderate to severe, oxygen therapy is also recommended. Management is conservative. Studies show these patients can be managed with "expectant outpatient observation without further imaging". They report repeat imaging did not change outcome or management. Spontaneous pneumomediastinum is generally regarded as a "benign condition that resolves without consequence". Upon admission, this patient did not receive any highly skilled or technical care. The only medication that was administered after his admission to the pediatric floor was an oral dose of ibuprofen. He improved without complication. His radiological studies did not demonstrate any airway compromise and his presentation did not suggest he would be prone to an adverse outcome.
Based on these findings, the patient did not meet criteria for an inpatient level of care.