Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Mild bronchiolitis.

Treatment: Inpatient Admission.

The insurer denied coverage for the Inpatient Admission.

The denial is upheld. 

This is a male patient with history of atrial fibrillation, asthma, and questionable pulmonary embolism (PE) in the past.  The patient was on Eliquis.  The patient presented to the Emergency Department (ED) with complaints of dyspnea on exertion (DOE), pleuritic chest pain, epigastric pain and some productive cough.  The patient also complained of some nausea, vomiting and epigastric pain.  This patient was taking famotidine and had run out of the medication.  The patient's symptoms felt better when he was taking famotidine. The patient's vital signs at ED presentation were: temperature 37.3, respiratory rate 18, blood pressure 116/76, heart rate 85 and oxygen saturations 98 % on room air. On exam, the patient was in no acute distress (NAD). The patient had clear lung fields on auscultation. The patient's cardiovascular system (CVS) was normal.  The patient was alert and oriented. The patient's white blood cell (WBC) count was 6200, hemoglobin (Hb) 15.7, electrolytes within normal limits (WNL), blood urea nitrogen (BUN)/ creatinine ratio was 15/1, and troponin <0.012.  The patient's chest X-ray showed no acute infiltrates. The patient's electrocardiogram (EKG) showed no acute changes. The patient's influenza screen was negative. The patient's computed tomography angiogram (CTA) of chest was negative for pulmonary embolism (PE); there was mild atelectasis at the lower lobe; the tree in bud appearance right lower lobe (RLL) was consistent with bronchiolitis. The patient was given 1 dose of ceftriaxone and azithromycin for possible community-acquired pneumonia (CAP).  The patient was subsequently admitted to the hospital.  As per History & Physical (H&P), the patient was in no acute distress (NAD).  The patient's vital signs were: temperature 99, heart rate 77, respiratory rate 20, blood pressure 141/80 and oxygen saturations 97 % on room air. The patient's lungs were clear to auscultation. The patient's cardiovascular and abdominal exams were all unremarkable. The patient was alert and oriented, with no focal neurological finding on exam. The patient was seen by Infectious Diseases (ID).  ID did not recommend any antibiotics.  So, the patient's antibiotics were discontinued.  The patient was seen by Cardiology; Cardiology discontinued Cardizem for the patient.  The patient was treated with Symbicort, albuterol and was continued on Eliquis and famotidine. The patient remained stable after admission.  The patient was discharged the next day on oral (PO) medications.

Based on the review of the medical record and literature, this patient did not need acute inpatient hospitalization.  The patient could have been placed in observation status (which could be up to 48 hours) while diagnostic testing and treatment were initiated.  The patient was afebrile and hemodynamically (HD) stable.  There was no evidence of pulmonary embolism; myocardial infarction (MI) was also ruled out. The patient's white blood cell (WBC) count was normal.  The patient was not hypoxic.  The patient was on oral (PO) medications.  There was no evidence of pneumonia, pulmonary embolism or myocardial infarction.  The patient's gastrointestinal (GI) symptoms had improved with famotidine.  This patient had mild bronchiolitis and was stable for discharge after a period in observation status. 

The health plan acted reasonably with sound medical judgment, and in the best interest of the patient.

The insurer's denial of coverage for the Inpatient Admission should be upheld.