Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anaphylaxis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission 

The denial is overturned

The patient has a history of food allergy to oranges, admitted for anaphylaxis after accidentally ingesting orange. The patient required epinephrine x 2, intravenous (IV) Benadryl, and Solumedrol. The patient was admitted overnight for monitoring. The following day, the patient had recurrence of itchiness and required Benadryl. The patient was discharged the following day.

The patient had anaphylaxis requiring two epinephrine injections and needed to be monitored. The following day, the patient had itchiness requiring IV Benadryl. Given that the patient's symptoms had not resolved and the patient had recurrence, monitoring of symptoms was in the best interest of the patient.      

"Anaphylaxis is a life-threatening systemic reaction, normally occurring within one to two hours of exposure to an allergen. The incidence of anaphylaxis in the United States is 2.1 per 1,000 person-years. Most anaphylactic reactions occur outside the hospital setting. Urticaria, difficulty breathing, and mucosal swelling are the most common symptoms of anaphylaxis. The most common triggers are medications, stinging insect venoms, and foods; however, unidentified triggers occur in up to one-fifth of cases. Coexisting asthma, mast cell disorders, older age, underlying cardiovascular disease, peanut and tree nut allergy, and drug-induced reactions are associated with severe or fatal anaphylactic reactions. Clinicians can obtain serum tryptase levels, reflecting mast cell degranulation, when the clinical diagnosis of anaphylaxis is not clear. Acute management of anaphylaxis involves removal of the trigger; early administration of intramuscular epinephrine; supportive care for the patient's airway, breathing, and circulation; and a period of observation for potential biphasic reactions. Only after epinephrine administration should adjunct medications be considered; these include histamine H1 and H2 antagonists, corticosteroids, beta2 agonists, and glucagon. Patients should be monitored for a biphasic reaction (that is (i.e.), recurrence of anaphylaxis without re-exposure to the allergen) for four to 12 hours, depending on risk factors for severe anaphylaxis. Following an anaphylactic reaction, management should focus on developing an emergency action plan, referral to an allergist, and patient education on avoidance of triggers and appropriate use of an epinephrine auto-injector" (Pflipsen, M. C., & Vega Colon, K. M. 2020).

"Anaphylaxis is a potentially life-threatening, multisystem allergic reaction that can cause airway, breathing, or circulatory compromise. Intramuscular epinephrine is the immediate treatment of all patients. Intravenous epinephrine should be used in patients in shock, either as a bolus or infusion, along with fluid resuscitation. Airway obstruction must be recognized, and early intubation may be necessary. For shock that is refractory to epinephrine, additional vasopressors may be needed. Disposition depends on patient presentation and response to treatment. Mandatory observation periods are not necessary, because biphasic reactions are difficult to predict and may occur outside of typical observation periods" (McHugh, K., & Repanshek, Z. 2022). 

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 the inpatient admission is substantiated.