Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Shortness of breath.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is overturned.

The patient is a female. She presented to the Emergency Room for evaluation of shortness of breath. Her medical history was significant for COPD (chronic obstructive pulmonary disease), oxygen at 3 L/min (liters per minute) at night, atrial fibrillation, OSA (obstructive sleep apnea) on CPAP (continuous positive airway pressure) , dyslipidemia, obesity and hypertension.

The patient's chest x-ray was positive for pulmonary vascular congestion. Her COVID test resulted as positive. She had an oxygen saturation of 88% on room air. She was placed on 4 L/min (liters per minute) supplemental oxygen. She received IV (intravenous) Decadron and IV (intravenous) Lasix. She was admitted with COVID 19 infection and hypoxemia. She received IV (intravenous) Remdesivir. The patient improved and was discharged.

Yes, the Inpatient admission was medically necessary.

The patient is a female. She presented to the Emergency Room for evaluation of shortness of breath. Her medical history was significant for COPD (chronic obstructive pulmonary disease), oxygen at 3 L/min (liters per minute) at night, atrial fibrillation, OSA (obstructive sleep apnea) on CPAP (continuous positive airway pressure) , dyslipidemia, obesity and hypertension.

The patient's chest x-ray was positive for pulmonary vascular congestion. Her COVID test resulted as positive. She had an oxygen saturation of 88% on room air. She was placed on 4 L/min (liters per minute) supplemental oxygen. She received IV (intravenous) Decadron and IV (intravenous) Lasix. She was admitted with COVID 19 infection and hypoxemia. She received IV (intravenous) Remdesivir. The patient improved and was discharged.

The patient was noted to have Hypoxemia on presentation. She had Oxygen saturation of 88% on room air, and she required increased supplemental oxygen to 4 L/min (liters per minute), which was above normal baseline requirements.

The patient was treated her for COVID-19 pneumonia with remdesivir and dexamethasone. Within 24 hours, she felt significantly better and was able to be taken off oxygen within 2 - 3 days. She had been up and ambulating in the room. She did briefly drop down to 86%, but then quickly within few seconds at rest, went back up to 90.

The patient felt significantly better and indicated her preference to be discharged home. The patient presented with hypoxemia, requiring oxygen 4 liters/ minute and was also noted with COVID infection. In addition, she has risk factors including HTN (hypertension), Obesity, COPD (chronic obstructive pulmonary disease) that may be concerning for her hypoxemia to worsen with COVID infection. The patient was treated with IV (intravenous) Remdesivir, IV (intravenous) decadron, IV (intravenous) lasix, nebulizer and oxygen.

Considering the above treatments and the presence of hypoxemia requiring 4 liters oxygen, admission to the hospital was medically appropriate to ensure that no further deterioration happens in this patient and that she continues to recover. In the absence of hospital admission, adequate and close monitoring of this patient would not have been possible to maintain. Therefore, admission to the hospital was medically necessary. It was good that the patient responded appropriately and quickly and was able to be discharged quickly. Considering the baseline medical risk factors that she has, the severity of presentation, medical admission and treatment with IV (intravenous) meds was medically necessary for this patient.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.