Appeal type: Medical necessity
Decision: Upheld

Diagnosis: COVID
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is upheld.

The patient is an adult female. Her past medical history is significant for Diabetes, Hypertension, Gout; history of Large B cell lymphoma - on chemotherapy last session earlier this year (not on steroids). She also has a past history of admission for neutropenic fever. The patient presented with symptoms of fever, fatigue, malaise, nausea, cough and sniffles for two to three days. The patient denied chest pain or vomiting. The patient's vitals in the emergency room were Temperature - 101.2 Fahrenheit; Respiration rate - 20, Pulse - 84, Pulse oximetry 95% to 97% on room air. Laboratory results showed COVID -19 positive, Hgb (hemoglobin) 8.3, Hct (hematocrit) 25.9, CRP (C-reactive protein) 2.769, Dimer 495, Ferritin 707.9, Uric Acid 8, LDH (lactate dehydrogenase) 332. The patient was stared on treatment with antibiotics - Cefepime, Vancomycin; antiviral Remdesivir and on oxygen supplementation. Home medications were continued. The patient was evaluated by Infectious disease consult during hospital stay and antibiotics were de-escalated to Ceftriaxone, doxycycline. The patient continued to be stable and was discharged home on day #3.

The Inpatient admission was not medically necessary.

The patient had a history of B cell lymphoma with no recent chemotherapy in the prior four weeks before admission. The patient has history of diabetes but was on medications for this. The patient had also not been on continued steroids prior to admission. On presentation to the emergency room, the patient was positive for COVID. However, the patient had stable BP (blood pressure), pulse and oxygenation. The patient did not 
have shortness of breath, respiratory distress, confusion or altered mental status. The patient was febrile on admission; however other vital signs were stable. The clinical evaluation, and review of lab results did not show any findings to indicate patient had sepsis / septic shock that may need inpatient admission for treatment. The patient did not have symptoms or intractable pain that would require continued management in an inpatient setting. The patient was tolerating oral intake and was clinically stable. Physical exam for this duration did not show any new exam findings that would necessitate further work up in an inpatient setting. Lab results were stable and did not reveal abnormalities that would indicate further need for work up or change in management plan in an inpatient setting. During 
the above duration, there were no new investigations ordered / work up initiated, and there was no change in management plans that would justify / necessitate continued inpatient stay in the 
hospital. The patient was able to eat food, drink fluids and take oral medications. Although the patient had pain, it was not intractable, and noted to be amenable to appropriate oral treatment. Care rendered during this time was of low intensity, routine nursing and physician monitoring. No systemic findings such as shock, renal or liver failure or abnormalities of electrolytes or mental status were noted during this time. Examination findings were not concerning, and the patient's medical problems did not pose an immediate high risk of deterioration. Since the intensity of interventions was routine, ongoing inpatient care was not medically necessary during this time. With a low severity of illness and low intensity of interventions during this time, with relative clinical stability, lack of comorbid unstable conditions, and lack of intractable symptoms, ongoing inpatient care was not medically necessary for the above dates. In view of these findings therefore, the ongoing inpatient level of care for the above duration was not medically necessary.