Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Coronavirus (COVID -19) pneumonia
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is modified
 
This case involves an adult male who presented to the emergency department complaining of shortness of breath, dizziness, and left-hand numbness that began 1 hour prior to his arrival.  He tested positive for COVID-19 five days before and then tested negative the day prior.  He denies chest pain, orthopnea, paroxysmal nocturnal dyspnea (PND), slurring of speech, weakness of the extremities, or headaches.  He was a non-smoker but had crepitation present on the right lung base.  Laboratory values were abnormal with white blood cell count at 13.2, blood urea nitrogen low at 7.5, potassium low at 3.3, alanine transaminase (ALT) elevated at 64, aspartate aminotransferase (AST) elevated at 88, pH elevated at 7.46, partial pressure of oxygen (PO2) low at 47.9, and oxygen saturation at 80.9.  Vital sign assessment noted a pulse of 123, respirations 20, blood pressure 131/80 and pulse oximetry 97%(percent) on room air.  The patient received 2 liters of oxygen via nasal cannula.  He received intravenous fluids and was recommended for imaging.  

The assessment was acute hypoxic respiratory failure due to COVID-pneumonia, hypertension, hyperlipidemia, elevated liver function testing, with active problems consisting of COVID-19 and hypoxia.  

Records indicated the patient showed improvement 4 days before discharge.  Vital signs were stable.  The patient remained on inpatient status until discharge four days later.  

According to the Milliman Care Guidelines, inpatient admission for individuals who are found to have pneumonia must include evidence that have either confirmed hypoxemia, that they are hemodynamically unstable, have altered mental status that is severe persistent, dehydration that is severe persistent, with a require ventilatory assistance, if the patient is in the moderate risk category for high risk category, has failure of outpatient treatment, as respiratory findings such as tachypnea that persist despite observation care, have complicated pleural effusions to include empyema or loculated, when there is presence of risk factor for poor outcome, such as gross hemoptysis, cavitary infiltrate, neuromuscular weakness, or cystic fibrosis, or if the patient requires isolation that cannot be performed outside the hospital setting.  The information provided for the review claimed that the patient had tested positive for COVID-19 five days before he arrived at the emergency department.  He was negative the day before his arrival, and he presented with complaints of shortness of breath, dizziness, and left-hand numbness.  The admitting physician stated that the reason for inpatient care was due to acute hypoxic respiratory failure secondary to COVID-19 pneumonia.  However, the chest X-ray did not confirm evidence of pneumonia, the patient was negative for COVID the day before he arrived at the emergency department, and aside from an elevated pulse, he was not showing signs or symptoms of acute respiratory distress.  The patient's respiratory rate was not found to have serial escalation, and while auscultation of the lungs noted scattered rhonchi heard bilaterally, the full inpatient stay was not a medical necessity.  The patient had stabilized after the initial days. Therefore, while inpatient stay was appropriate and within the standard of care for the initial two days, the continued hospital admission was not medically necessary.

Based on the above, the insurer's denial must be modified. The health care plan act reasonably in part. The medical necessity for full hospital admission is not substantiated. Medical necessity is partially substantiated.