Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Angioedema
 
Treatment: Inpatient Admission

The insurer denied the Inpatient Admission. The denial was upheld.   

This is a female patient with a medical history of seizure disorder, hypertension, and alcohol abuse who presented to the Emergency Department (ED) with upper lip swelling, scratchy throat and two seizures. She had an electrocardiogram (EKG) which revealed inferolateral ischemia. She had an extensive laboratory work up that showed a white blood cell count (WBC) 10.74, a blood alcohol level of 4, blood urea nitrogen (BUN) level of 19, sodium 132, and a platelet count of 122. Her urine tested positive for benzodiazepines. She was treated in the Critical Care Unit (CCU) with intravenous (IV) fluids, Decadron, Ativan, Librium, magnesium sulfate and two units of fresh frozen plasma (FFP). The patient signed out against medical advice (AMA).

While the patient had swelling and elevated CPK levels, there was no record of renal failure, airway failure or other severe signs and symptoms.  The patient could have been managed at a lower level of care such as observation level of care.  Therefore, the inpatient admission in question was not medically necessary. The insurer acted reasonably, and with sound medical judgment, and in the patient's best interest. 

Per Bernstein, J. A., Cremonesi, P., Hoffmann, T. K., & Hollingsworth, J. (2017), "Patients without involvement of the tongue or larynx and with no other threat to the airway (Ishoo stage I; Ishoo grading is not validated but may be helpful as a guide) can be discharged after a number of hours of observation (26 h or longer as necessary) to ensure that symptoms have begun to resolve with no indication of development of airway obstruction.  Discharge should not occur unless the airway has been assessed as Ishoo stage I or below.  Patients with mild angioedema of the lips may be discharged with specific treatment if no further progression is observed."

Per Long, B. J., Koyfman, A., & Gottlieb, M. (2019), "Angioedema is non-dependent, non-pitting edema at a variety of sites. Its forms can be divided into histamine-mediated and bradykinin-mediated types. Histamine-mediated forms can present similarly to anaphylaxis, while bradykinin-mediated angioedema is slower in onset, presents with greater face and oropharyngeal involvement, and has higher risk of progression.  Initial evaluation and management should focus on the airway, followed by an evaluation for family history. 

Per Sandefur, B. J., E Silva, L., Lohse, C. M., Goyal, K. A., Barbara, D. W., Castaneda-Guarderas, A.,  Campbell, R. L. (2019), "Among 450 adult angioedema patients, the mean +/ standard deviation age was 57 +/ 18 years, and 264 (59%) were female. Among patients, 30% had suspected nonhistaminergic angioedema, 30% had suspected histaminergic angioedema, and 40% were of unknown etiology.  As compared to histaminergic angioedema, nonhistaminergic angioedema was associated with angiotensin-converting enzyme inhibitors (ACEI) or use of angiotensin II receptor blockers (ARB) (odds ratio [OR] [60.9]; 95% confidence interval [CI], 23.16160.14) and time of onset one hour or more prior to ED arrival (OR [5.91]; 95% CI,1.8718.70) and was inversely associated with urticaria (OR [0.05]; 95% CI, 0.020.15), dyspnea (OR [0.23]; 95% CI, 0.080.67), and periorbital or lip edema (OR [0.25]; 95% CI, 0.080.79 and OR [0.32]; 95% CI, 0.130.79, respectively)."                                                         

Therefore, the inpatient admission in question was not medically necessary. The insurer acted reasonably, and with sound medical judgment, and in the patient's best interest. 

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