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 young adult male with morbid obesity who was diagnosed with COVID-19 (coronavirus disease) four weeks prior to presentation to the hospital for increasing dyspnea. He had seen his primary care physician and was given Ventolin prescription for management of dyspnea and wheezing but symptoms had continued to progress. 

On presentation, the patient had tachycardia, leukocytosis, wheezing, crackles on lung examination and morbid obesity documented. Computed tomography (CT) scan of the chest documented ground glass opacities bilaterally and oxygen saturation was 92% on room air. Lactate level was 2.2, elevated. He was placed on supplemental oxygen. Remdesivir and steroids were administered and the patient's condition improved, leading to discharge three days later. 

The reason for denial is that the patient's condition was too mild to require inpatient hospitalization based on Milliman Care Guideline (MCG) criteria. The reason for appeal includes all the clinical elements mentioned in the clinical summary and the concern for deterioration due to COVID-19 and hypoxemia.

The proposed inpatient hospital admission was medically necessary.

Inpatient care is recommended when a patient's symptoms, signs, imaging data, and labs suggest a moderate to severe illness that is acute. Additional factors to take into consideration are the presence of co-morbid conditions, the relative instability of such co-morbid conditions, and the risk of deterioration. The judgement of severity and risk is based on an assessment of medical factors in the context of known and generally accepted medical knowledge prevalent at the time of determination. Moderate to high intensity interventions that are required for evaluation and management of the condition also justify an inpatient level of care. Final factors to take into account when judging whether an inpatient admission is medically necessary is the availability of evaluation and management in the outpatient setting in an expeditious manner, as mandated by the patient's clinical condition, and appropriate for the patient's medical condition. 

In this case, the patient had morbid obesity, a diagnosis of COVID-19, ground glass opacities documented on computed tomography of the chest, oxygen saturation of 92% on room air, need for supplemental oxygen and worsening dyspnea that failed to respond to outpatient Ventolin treatment, with wheezing and crackles documented on examination. As indicated in the references, this is a medical scenario that meets the National Institutes of Health (NIH) criteria for hospitalization for patients with COVID-19 and general standards of practice. Obese persons, males, and those at the three to four week mark from onset of symptoms with tachycardia are at risk for deterioration and need for oxygen support, steroid therapy and potential immune modulatory treatment as well as anti-viral treatment. These interventions are most judiciously, safely and efficaciously provided in the inpatient setting.