Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Urticaria

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

The patient presented to the emergency room (ER) for diffuse urticaria. The patient reported itching that started 2 days prior. The rash initially started distally in the hands and then progressed toward the trunk. The patient has some areas of their scalp that are itchy as well. The patient noted that they had some lymph nodes in the back of their neck and scalp. The patient reported taking Benadryl which did not provide any relief.  The patient also reported subjective fever and chills at home. The patient was admitted for diffuse urticaria from possible allergic reaction versus viral illness. Benadryl intravenous (IV), 60 milligrams (mg) of prednisone, urinalysis, human immunodeficiency virus (HIV) testing, and a one-time dose of IV dexamethasone were ordered. The patient's Chest X-ray (CXR) was negative. 

An Infectious Disease (ID) consult was done for an elevated white blood cell (WBC) count. During the consultation, the patient complained of diffuse pruritus. The patient also mentioned that they received contrast for the first time for the computed tomography (CT) scan but the patient did not feel any immediate symptoms such as nausea, vomiting or rash. Upon examination, the patient is in mild distress, there were clusters of small bumps radiating centripetally from the fingertips to the abdomen, and mild urticaria on the abdomen and the back. 

In this case, the patient presented to the ER for an allergic reaction.  The patient complained of hives, erythema to body, head, and neck that are very itchy and swollen. The patient stated that they also presented to the ER 4 days prior for a stab wound to the abdomen. In the ER, vital signs were: temperature (T) 98.4 Fahrenheit (F), pulse 104, blood pressure (BP) 127/71, oxygen (O2) saturation 99%. The patient's WBC was 27.5. Treatment was initiated with Benadryl oral (PO) and prednisone 60mg PO which did not help. Epinephrine (Epi) 0.3mg was given, and the patient was placed on cardiac monitor with slight improvement. Several hours after epi, the patient was still very itchy and erythematous so the patient was admitted. Infectious Disease consult was done for elevated WBC. During the consultation, the patient complained of diffuse pruritus. The patient also mentioned that they received contrast for the first time for the CT scan but did not feel any immediate symptoms such as nausea, vomiting or rash. Upon examination, the patient is in mild distress, there were clusters of small bumps radiating centripetally from the fingertips to the abdomen, mild urticaria on the abdomen and the back. 

Per the Milliman Care Guidelines (MCG), skin disease or infection requiring inpatient care is indicated for urticaria too severe for observation care (e.g., requires ongoing intravenous treatments, extended monitoring for anaphylaxis or respiratory compromise). According to the medical records, treatment was initiated with Benadryl PO and prednisone 60mg PO which did not help. Epi 0.3mg was given, and the patient was placed on cardiac monitor with slight improvement. Several hours after epi, the patient was still very itchy and erythematous so the patient was admitted. In addition, the referenced literature stated that urticaria can be misdiagnosed as other skin condition and further investigation is needed to allow an accurate diagnosis. As such, the inpatient admission is medically necessary due to the failed treatment rendered in the ER. In addition, the patient was started with Benadryl IV. Therefore, the denial of coverage for hospital inpatient services is overturned. 

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for hospital inpatient services is substantiated.