Appeal type: Medical necessity
Decision: Overturned


Diagnosis: Rash
Treatment: Inpatient stay
The insurer denied: Inpatient stay
The denial is: Overturned.

The patient is a male with a past medical history significant for depression and tonsillectomy who presented to the emergency department with an allergic reaction that started one day before the presentation. The patient complained of a skin rash on his arms. He stated that the rash was spreading. Reportedly, he was seen by a physician in the urgent care before the presentation to the emergency department and was prescribed Prednisone and Ranitidine, which he took early on the day of admission. Since his skin rash did not improve and the patient started to feel dizzy and short of breath, he came for further evaluation.

In the emergency department, the patient received treatment with intravenous fluids, Benadryl, and Pepcid with improvement of his symptoms. He was discharged from the emergency department with a prescription for EpiPen and corticosteroids, but his skin rash and swelling reappeared and that prompted the patient to come back to the emergency room (ER), and he was admitted. The patient was worried about going into anaphylaxis. He said that he lived alone.
In the hospital, the patient was seen by a dermatologist, who indicated in the consultation note that the patient had urticaria and angioedema. Possible triggers of his allergic reaction included recent pre-exposure prophylaxis (PrEP), Wellbutrin, tetanus, diphtheria and pertussis (TDaP) vaccine, or use of non-steroidal anti-inflammatory drugs (NSAIDs). The dermatologist recommended corticosteroid taper as well as standing antihistamines, avoiding NSAIDs, and staying off PrEP and Wellbutrin.

The ear, nose and throat (ENT) specialist recommended treatment with intravenous Decadron for epiglottic mucosal edema.
During the hospital stay, the patient's clinical condition gradually improved, and he was discharged from the hospital.

The requested inpatient stay was completely justified for this patient due to the severity of the condition, increased chances of worsening angioedema and airway compromise, and the need for administration of intravenous corticosteroids and close monitoring of airway patency, and respiratory status.
The patient had an allergic reaction that manifested in urticaria and some shortness of breath, which could be related to epiglottic mucosal edema. Therefore, the patient required treatment with intravenous corticosteroids and close monitoring of the airway, for signs of respiratory distress and hypoxia.
According to the nationally accepted standards of care, the presence of epiglottic edema in the setting of angioedema and allergic reaction justify admission at the acute inpatient level.
This is confirmed by the Milliman Care Guidelines (MCG)MCG Health General Recovery 25th Edition Systemic or Infectious Condition General Recovery Guidelines (GRG)GRG. According to these guidelines, admission at the acute inpatient level of care is justified for cases of allergic reaction and airway edema, including epiglottic edema.
Therefore, admission at the acute inpatient level of care was completely justified, for close monitoring and treatment of the potentially life-threatening condition.