Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Influenza
Treatment: Inpatient hospital stay
The insurer denied coverage for inpatient stay
The denial is upheld. 

The patient was a female with history of diabetes mellitus, chronic kidney disease, hyperlipidemia, hypertension, and osteoarthritis, morbid obesity who presented to the Emergency Department (ED) with a several day history of worsening shortness of breath, cough, chest congestion and subjective fevers. The patient's cough was dry. The patient's vital signs at presentation to the ED were: Temperature 99.6, Blood Pressure116/81, Respiratory Rate 16, Heart Rate 80, and Oxygen (O2) Saturation 96% on room air; the patient's body mass index (BMI) was 66. The patient was in no acute distress (NAD). The patient's cardiac exam was unremarkable. The patient's lung's exam revealed prolonged expiration with positive stridor and reduced airway entry, transmitted sounds and occasional wheezing. The patient was alert and oriented with a non-focal exam. The patient's laboratory results showed white blood cell count (WBC) of 3.7, hemoglobin of 14, BUN/Creatinine of 17/1.3. The patient's venous blood gas showed pH of 7.38, CO2 of 55, O2 of 51, and HCO3 of 33. The patient's chest x-ray revealed mild congestion. Retrocardiac infiltrate could not be rule out. The patient's electrocardiogram (EKG) showed no acute changes. The patient was tested positive for influenza A. 

The patient was treated with bronchodilators via nebs, oral prednisone, maintenance cardiac medications, Tamiflu, azithromycin and Rocephin. The patient's labetalol dose was increased to treat for her elevated blood pressures. As per ED notes, the patient was not in acute distress and was noted to be ambulatory to bathroom. The patient's oxygen saturation was 94% on room air. As per the history and physical note, the patient was again noted to be in not in acute distress; the vital signs were temperature of 99.3 F, respiratory rate of 16, blood pressure of 142/98 mm Hg, heart rate of 79, and oxygen saturation of 94% on room air. The patient's lung exam revealed decreased airway entry and a normal cardiovascular exam. The patient remained stable after admission. The patient was oxygenating appropriately without supplementation, ambulating and tolerating oral intake. There were no clinical signs of pneumonia, including an unremarkable chest x-ray. The patient's echocardiogram showed left ventricular hypertrophy with ejection fraction of 65%. The patient remained afebrile and hemodynamically stable. The patient was discharged on oral medications.

Based on the review of the medical record and literature, this patient did not need acute inpatient hospitalization. The patient had influenza but was afebrile and hemodynamically stable. The patient was tolerating oral intake, and was oxygenating well, greater than 92% on room air. The patient could have been placed in observation status while diagnostic testing and treatment were initiated. The patient's clinical workup was negative for pneumonia. The patient could have been safely treated with oral antibiotics. The patient remained stable after admission and could have been discharged home after a period of observation and followed closely in an outpatient setting. Thus, inpatient admission was not medically necessary.

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

Based on the above, the medical necessity for the inpatient hospital admission is not substantiated.  The insurer's denial should be upheld.