Appeal type: Medical necessity
Decision: Upheld

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

This patient is an adult male. He was referred to the emergency department by his primary care physician (PCP) for evaluation of chills, fever, shivering, and shortness of breath after testing positive for COVID by a rapid test. His past medical history includes stage 4 chronic kidney disease, hypertension, and heart failure with reduced ejection fraction (HFrEF) with left ventricular ejection fraction (LVEF) 30% (percent). The patient's vitals were stable after treatment. His breathing was unlabored. There was no 
abdominal pain or tenderness. Labs showed hyperglycemia, increased blood urea nitrogen (BUN) above baseline, increased creatinine (Cr) above baseline, and elevated flat troponin, liver function tests (LFTs), and lipase. The patient's electrocardiogram (EKG) showed normal sinus rhythm (NSR) with non-specific T wave inversion. Transthoracic echocardiogram (TTE) showed a recovered ejection fraction of 60% and no decline to consider elevated troponin from COVID-19 myocarditis. Computed tomography (CT) scan of abdomen and pelvis revealed mild enlargement of the appendix, but no pancreatitis, and the surgeon recommended no surgical intervention. Renal function improved with intravenous fluids, medications were adjusted for hypertension control, and statin was discontinued due to the transaminitis. The patient improved and was deemed medically stable for discharge to home with close follow-up as an outpatient. The requested coverage for Inpatient admission has been denied by the health plan as not medically necessary. The denial is being appealed.

The Inpatient admission was not medically necessary.

Based on the peer-reviewed medical literature, including the MCG (Milliman Care Guidelines) Guidelines titled: 26th Edition: General Recovery Guidelines, GRG: PG-MDX (ISC GRG), Multiple Illness GRG, the inpatient admission was not medically necessary. The severity of this patient's illness did not meet the intensity of service for inpatient hospital stay. Criteria for inpatient stay are not met, including documentation of hemodynamic instability, hypoxia, respiratory distress, change in mental status, severe heart failure, cardiac arrhythmias of immediate concern, myocardial ischemia or myocardial infarction, positive troponin not explained by chronic kidney disease or congestive heart failure, hypertension requiring inpatient hospitalization, cerebrovascular accident, pulmonary embolism, aortic dissection, pneumonia, severe electrolyte abnormalities, or any other medical condition or other medical instability or acute care needs that would require acute inpatient management. In this particular case, there was no clinical decline or inadequate response to treatment that required inpatient hospital stay. The care that the patient received for an uncomplicated COVID-19 illness, a known inflammatory viral illness with mild dehydration, 
elevated troponin explained by reduced renal clearance and in the setting of improved left ventricular ejection fraction (LVEF) and mild transaminitis and elevated lipase without acute clinical pancreatitis, is routinely provided safely and effectively at a lower level of care. Therefore, the inpatient admission was not medically necessary.