Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anaphylaxis/Angioedema.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is overturned. 

The patient is a male child with medical history significant for eczema and peanut allergy (with anaphylaxis) that presented to the emergency department via Emergency Medical Services (EMS) after ingesting almonds. He had an episode of vomiting and developed rash on his face, arms, and abdomen. 

Vital signs included heart rate 141, respiratory rate 23, and blood pressure 105/74. Examination was significant for no acute distress, non-toxic appearance, congestion with rhinorrhea, moist mucous membranes, facial swelling with eyes almost swollen shut, clear lungs with stridor, benign abdomen, urticaria on the abdomen and face and bilateral upper extremities, and non-focal neurologic exam. He was treated with intramuscular (IM) epinephrine, Solumedrol, Benadryl, famotidine, and a normal saline bolus. He initially improved, with resolution of stridor, no wheezing, and improved facial swelling. However, upon re-evaluation after several hours, upper and lower extremity swelling had worsened, prompting a second dose of intramuscular (IM) epinephrine. The mother asked to watch in the emergency department (ED) for another couple of hours prior to admission. 

The patient was subsequently admitted after five hours of observation in the emergency department. Admission orders included continuous cardiac monitoring, continuous pulse oximetry, routine enteral Benadryl, routine parenteral corticosteroids, routine enteral famotidine, intramuscular (IM) epinephrine available as needed for recurrence of symptoms, regular diet, and outpatient referral to Allergy/Immunology. The swelling improved, the patient remained afebrile and hemodynamically stable. He did not require additional epinephrine administration. He was deemed stable for discharge after more than fifteen hours of clinical stability and no recurrence of anaphylaxis.

Yes, the proposed inpatient admission was medically necessary.

Acute inpatient admission was medically necessary and appropriate in this case. 

Anaphylaxis is a life-threatening hypersensitivity reaction to something in the environment. Onset is sudden and typically dramatic, with respiratory, skin, and gastrointestinal manifestations. There are multiple triggers, including foods, insect stings, and medications. Foods are the most common triggers in the pediatric population. Because anaphylaxis is a medical emergency, treatment must be rapid. Current guidelines agree that epinephrine is the first medication of choice because it is the only medication shown to reduce hospitalization and death. Second line treatments include antihistamines (H1 [histamine 1] and H2 [histamine 2]) and glucocorticoids. Because symptoms may return as epinephrine is metabolized by the body, it is important to monitor patients depending on risk stratification. For standard risk patients, monitoring for three or four hours in the emergency department should be sufficient. For medium risk patients, those with history of asthma, mild wheezing upon presentation, slow resolution of symptoms, a longer period of observation is appropriate, six to eight hours. For high risk patients, those that have received two or more doses of epinephrine, that present with moderate to severe wheezing, hypotension, pharyngeal edema, or worsening of symptoms, hospitalization is appropriate. 

This young male child with history of eczema, severe peanut allergy, and reactive airways disease presented with angioedema, stridor, vomiting, and urticaria after eating almonds. He responded well to comprehensive aggressive treatment initially but after several hours, symptoms returned prompting administration of a second dose of epinephrine. With his medical history, young age, high risk clinical presentation, and response to treatment in the emergency department, acute inpatient admission was medically necessary. The care the patient received was consistent with that level of management. A lower level of care would not have been appropriate in this case.