Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Painful Mouth Sores and Vomiting.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is overturned. 

The patient is a male who presented to the emergency department for evaluation of hemoptysis and throat pain. The patient had ran out of medications (steroids) about a month ago and two days before presentation to the emergency department, the patient started experiencing fever, chills, hemoptysis, headache, weakness and inability to eat or drink due to oral lesions. The patient also had complaints of dizziness and intractable pain to the oral lesions. 

On evaluation in the emergency room, the patient was noted to be febrile (temp 100.3F) and heart rate was 98 beats per minute. The patient had rash (maculopapular rash to plaques with open wounds) scattered throughout the legs, trunk and back. Examination also showed multiple excoriated oral lesions.  The patient reported intermittent fever, chills, nausea and non-bloody vomiting for the last three days before presentation to emergency department. 

Labs showed a white blood cell (WBC) count of 12.7 thousand, blood urea nitrogen (BUN) of 14, and creatinine of 1.3. The patient also underwent computed tomography (CT) of the head due to complaints of headache and fever. The patient was treated with intravenous Zofran and was started on intravenous antibiotics Zosyn / Vancomycin. The patient was also treated with intravenous prednisone and intravenous fluids. 

The patient was admitted for further evaluation and treatment in view of risk for bacteremia in view of fever and multiple open skin wounds. The patient also to maintain adequate oral intake and treated with intravenous fluids.  The patient was admitted for rule out sepsis and started on intravenous antibiotics. Also, there was clinical concern for exacerbation of pemphigus vulgaris and the patient was started on intravenous steroids (solumedrol). Consultation was requested from Infectious disease and Ear, Nose and Throat (ENT).

Inpatient hospital stay is justified and medically necessary when a patient's symptoms, signs, labs and imaging indicate severe illness, high risk of deterioration, unstable comorbid conditions and the need for high intensity, complex and frequent interventions and evaluation. Inpatient care is recommended when a patient's symptoms, signs, imaging data, and labs suggest a moderate to severe illness. 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 are based on assessment of medical factors in the context of known and generally accepted medical knowledge prevalent. 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 alternate setting in an expeditious manner, as mandated by the patient's clinical condition, and appropriate for the patient's medical condition. 

This patient presented with fever, vomiting, inability to maintain oral intake and was started on treatment with intravenous fluids, intravenous antibiotics and also required intravenous steroids to treat for pemphigus vulgaris. The patient had multiple skin ulcerations that put him at risk for infection / bacteremia and so intravenous antibiotics were needed. 

Based on above clinical presentation, admission to inpatient care (inpatient hospital admission) was needed to ensure adequate treatment and to monitor the patient to confirm response to treatment and to confirm that patient's condition does not deteriorate going further.