Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Near Syncope

Treatment inpatient hospitalization

The insurer denied coverage for inpatient hospitalization

The denial is upheld

The patient has a history of asthma, anxiety, mitral valve prolapse (MVP), bilateral ocular melanoma, left (L) ovarian cyst, migraine and a "small benign brain tumor." The patient presented to the emergency department (ED) after a 19-day hospitalization for Coronovirus. The patient was discharged home with a walker but not on oxygen (O2).  
As per the history, the patient apparently had desaturation to 70's on ambulation. Mother also reported some episode of unresponsiveness and cyanotic episode during the day with desaturation to 60's.  Emergency medical services (EMS) placed the patient on non-rebreather (NRB) at her home with improvement in O2 saturations to 100% (percent).  
Vital signs in the emergency department (ED) were Temperature 97, Heart Rate 76, Respiratory Rate 24, and Blood Pressure 104/52 and oxygen (O2) saturations were 100%. On ambulation, O2 saturations decreased to 80% on room air. The patient was weaned down to 2 Liters of O2 via nasal cannula (NC).  The patient was in no acute distress (NAD). Lungs were clear and cardiovascular system (CVS) was normal. The abdomen was non tender (NT). The patient was alert and oriented to person, place and time.  The neurological exam was grossly non focal neuro exam.  Initial labs were white blood cell count (WBC) was 6.2K (thousand), hemoglobin (Hb) was 13, Electrolytes and blood urea nitrogen (BUN)/Creatinine were within normal limits within normal limits. D-Dimer was normal, Troponin was normal, an electrocardiogram (EKG) showed normal sinus rhythm without acute changes. Chest x-rays revealed no acute pathology.  Head computed tomography (CT) was negative. The patient had a CT of the chest done to rule out pulmonary embolism. No pulmonary pathology was noted.  The patient was treated with Albuterol, Symbicort and O2 by NC. She was continued on maintenance Dexamethasone of 2 mg (milligrams) oral (PO). The patient also placed on Valium.  The patient was admitted to the hospital for further work up.  The patient remained stable after admission. She was afebrile and hemodynamically (HD) stable. O2 saturations were stable. The patient was in no acute distress. Physical exam was unremarkable.  The patient was evaluated by Psychiatry and Neurology. Neurology recommended to Continue migraine meds. A magnetic resonance image (MRI) was recommended to be done as outpatient and further follow up (F/U) in outpatient setting. Psychiatry recommended the addition of SSRI (Selective serotonin reuptake inhibitors) for anxiety. The patient was ambulating freely, tolerating oral (PO).  The patient was discharged home.

This patient did not need acute inpatient hospitalization. She could have been placed in observation status while diagnostic testing and treatment were initiated. Observation could be for up to 48 hours. Differential diagnosis included long covid, seizure, anxiety /somatoform disorder. The patient had a negative work up. No lung pathology on CT. No evidence of Seizure. Myocardial Infarction (MI) and pulmonary embolism (PE) were ruled out.  This patient could have been discharged home after a period in observation. She remained stable after admission. Was afebrile and hemodynamically stable. If needed she could have been discharged on home O2 for a few days with further follow up (F/U) in outpatient setting. This patient had some lingering symptoms which could be attributed to long Covid.  Anxiety and Fatigue among them. Once acute diagnosis such as seizure, PE, and MI were ruled out the patient could have been discharged with further F/U in outpatient setting.

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

The insurer's denial of coverage for the inpatient hospitalization is upheld. Medical necessity is not substantiated.