Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Shortness of breath. 
Treatment: Inpatient hospital admission. 

The insurer denied the inpatient hospital admission. 
The denial is overturned. 

The patient is a male with a past medical history of tuberculosis. He has a history of pleural effusion, chest tube and questionable empyema. He presented to the emergency department with complaint of shortness of breath. He reported he was hospitalized in another country one month prior with tuberculosis and had a left chest tube placed. He had recently arrived from out of the country two days prior. He was assessed to have shortness of breath, fatigue, and diaphoresis. 

Yes, the inpatient hospital admission was medically necessary. 

The patient's vital signs were as follows: BP (blood pressure) 135/75 (BP Location: Left arm, Patient Position: Sitting), Pulse 112, Temperature 98.6 Fahrenheit (Oral), Respiration rate 16. He was in airborne isolation. On day one, XR (x-ray) chest revealed small left pleural effusion. On day one, CT (computed tomography) chest revealed trace left pleural effusion. There is scattered binasal atelectasis, more prominent on the left. 

On day one, Infection Control recommended continuing airborne isolation given active TB (tuberculosis) and associated complications are still much higher in differential. They were higher in this case as compared to possibility of MERS (Middle East Respiratory Syndrome). Requested for ID (infectious diseases) Consult. It was reasonable to place the patient in contact airborne special pathogen precautions given recent travel history. 

On day two, Infectious Disease advised to continue RIPE (Rifampin, Isoniazid, Pyrazinamide, and Ethambutol) and B6 [vitamin] to complete his initial 2 months with approximately 1 week left. He must then be transitioned to INH (Isoniazid) and rifampin for additional months. 

On day three, Department of Health (DOH) was contacted. The medications included IV (intravenous) NS (normal saline) bolus, ethambutol, isoniazid, pyrazinamide, pyridoxine, and rifampin. 

On day four, the patient was stable for discharge. The plan was outpatient follow-up PCP (primary care provider) and DOH. 

The patient presented with symptoms concerning for respiratory pathology. In view of past history of TB diagnosed out of the country and started on treatment there, there was high concern for this being active transmissible infectious TB. 

Admission to hospital was medically appropriate and necessary in view of above concern. In a clinical situation as above, it is medically appropriate that the patient be admitted to hospital on airborne isolation and then confirmed that he is not infectious before being discharged. Not admitting such a patient and discharging to the community is not medically appropriate. 

Admission to hospital in a scenario as above is important to ensure that patient is not infectious to the community at large and also to ensure that the patient is responding well to the current treatment and that the treatment is appropriate based on whatever additional information that can be obtained. 

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