Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Factitious Disorder
Treatment: Inpatient Hospital Admission
The insurer denied coverage for inpatient admission. 
The denial is upheld.

The patient is a female with past medical history of Factitious disorder, multiple other past medical issues including opioid dependency, fibromyalgia, psychosomatic disorder, Lupus, and anxiety.  The patient had been discharged from the hospital the previous day.  The patient presented with complaint of having an allergic reaction.  The patient complained of feeling tightness around her throat and also shortness of breath (SOB).  She took a Tablet of Prednisone and presented to the Emergency Department (ED).  

Vital Signs at presentation to the ED were temperature (T) 98.4, heart rate (HR) 141, respiratory rate (RR) 28, blood pressure (BP) 98/70 and oxygen (O2) saturations 100% (percent).  The patient was alert and oriented times (x) 3.  She was in no acute distress (NAD), throat was clear, and lungs clear.  Intentional upper throat wheeze is noted.  The patient was speaking full sentences.  The patient was given intravenous (IV) Steroids and Bronchodilators.  She was offered bi-level positive airway pressure (BIPAP) and Haldol but initially refused.  The patient later accepted. 

The patient improved initially after medications.  The patient was noted to be ambulating and running in ED to the bathroom.  White blood cell (WBC) count was 10.7K (thousand), hemoglobin (Hb) 15, and electrolytes were within normal limits (WNL).  There was mild hypokalemia.  Chest x-ray showed no acute infiltrates; improved atelectasis from prior film.  COVID (Coronavirus 2019) test was negative.  Arterial blood gas (ABG) was 7.47, pCO2 (partial pressure of carbon dioxide) was 28, pO2 (partial pressure of oxygen) was 197, HCO3A (bicarbonate) was 20, and O2 saturations 100%.

The patient was admitted to the hospital.  As per History & Physical, the patient was in no acute distress.  She was afebrile, HR 78, BP 100/82 mm Hg, and O2 saturations 100%.  The patient was hyperventilating, but was normal when distracted.  Her lungs were clear and she had intentional upper throat wheezes.  The patient was speaking full sentences.  Cardiovascular system (CVS) first heart sound (S1) and second heart sound (S2) revealed tachycardia.  The patient was alert and oriented x 3.

The patient was evaluated by Psychiatry.  Their diagnosis was Factitious Disorder.  They cleared the patient for discharge with oral (PO) Valium as an outpatient.  The patient signed out against medical advice (AMA) the next day.

This patient did not need acute inpatient hospitalization.  She had a known anxiety disorder and was discharged from the hospital just the previous day.  Her presentation was consistent with anxiety hyperventilation.  Her labs and ABG were normal.  Chest x-ray was unremarkable.  No acute pulmonary pathology is noted.  There were no signs of angioedema.  Her wheezing was described as intentional.  She was speaking normally and breathing normally when distracted.  The patient was ambulating, running normally in the ED.  O2 saturations were never below 100%.  The patient could have been placed in observation status while treatment, consultation and diagnostic testing were being done.  The patient remained stable overnight.  She could have been discharged home after a period under observation and completion of Psychiatric evaluation on PO medications with close follow-up in an outpatient setting.  

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

The insurer's denial of coverage for the inpatient hospital admission is upheld.  Medical necessity is not substantiated.