Appeal type: Medical necessity
Decision: Upheld

Diagnosis: COVID 19 (coronavirus disease 2019)
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The determination is upheld.

This is a patient with a past medical history significant for hypertension, chronic obstructive pulmonary disease (COPD), breast cancer in remission, peptic ulcer disease, and heart failure with reduced ejection fraction who presented to the hospital after she tested positive for coronavirus (COVID-19) 5 days before the presentation. The patient complained of chest pain, shortness of breath, body aches, and pain in the neck, shoulders, and legs. The review of systems was positive for pleuritic chest pain, abdominal pain, nausea, vomiting, diarrhea, a cough with white mucus, and a sore throat. The patient denied a fever.
Reportedly, the patient was evaluated at a different hospital 2 days before her presentation for the same symptoms. At that time, she underwent a computed tomography (CT) scan of the abdomen and pelvis due to complaints of diarrhea and abdominal pain. She received treatment with monoclonal antibodies and was discharged home. Following the treatment, she started to feel better for only one day, but subsequently, her symptoms worsened and she presented to the emergency department.
The patient was admitted to the hospital with acute respiratory failure that was attributed to a congestive heart failure (CHF) exacerbation and COVID-19. The admitting physician stated that the patient had cardiomegaly and pulmonary vascular congestion. The admitting physician stated that the patient was on room air and did not require supplemental oxygen throughout the hospitalization. The patient continued to have a cough throughout the hospitalization. She received treatment with diuretics.
According to the discharge summary, during the entire hospital stay the patient remained hemodynamically stable and afebrile with no significant laboratory abnormalities. The patient's clinical condition gradually improved, and she was transitioned to outpatient care. At issue is the medical necessity of an inpatient stay.

The hospital stay was not medically necessary for this patient at the acute inpatient level of care. The review of the medical records showed no evidence that the patient had hemodynamic instability, acute kidney injury, severe electrolyte abnormalities requiring inpatient care, cardiac arrhythmias of immediate concern, or the presence of acute decompensated conditions precipitating CHF such as pneumonia, or pulmonary embolism. The mild CHF exacerbation was possibly triggered by the COVID infection; however, the patient remained afebrile and did not require supplemental oxygen throughout the hospitalization.
The review of the medical records showed no evidence that the patient had severe pulmonary edema which required invasive or noninvasive assisted ventilation, massive skin edema, intractable pulmonary edema, persistent tachypnea, altered mental status, or acute peripheral ischemia. She did not require pulmonary artery catheter monitoring.
Overall, this patient remained in stable clinical condition and did not need any diagnostic studies or procedures necessitating admission at the acute inpatient level of care. There was no compelling clinical reason why the patient could not have safely and appropriately received evaluation and treatment at a lower level of care rather than admission to an inpatient level of care.