Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ears/Nose/Throat-Other-Odynophagia.
Treatment: Inpatient stay.
The health plan denied the inpatient stay as not medically necessary. 
The reviewer has upheld in whole the health plan's determination.

This is a patient admitted to the Hospital for a diagnosis of odynophagia. She presented with three days of right-sided throat pain after eating fish with a foreign body sensation associated with odynophagia and dysphasia. Vital signs demonstrated temperature 36.7 Celsius, pulse 83, blood pressure 114/83, respiratory rate 16 and oxygen (O2) saturation 100%. Physical exam showed no acute distress with normal oral mucosa without erythema, lesions, or bleeding. She underwent a flexible endoscope to examine the left nasal cavity, posterior oropharynx, hypopharynx, and larynx. She was found to have right arytenoid fold mild swelling but no gross evidence of fish bone. She was then discharged.

Medical necessity of an inpatient admission has not been established.
According to Up to date, 2020:
"Complications - Complications of foreign body ingestion or food impaction include perforation, obstruction, aortoesophageal fistula formation, and tracheoesophageal fistula formation.
Perforation - Patients with cervical perforations can present with neck pain, dysphagia, or dysphonia. Patients may have tenderness to palpation of the sternocleidomastoid muscle and crepitation due to the presence of cervical subcutaneous emphysema. Perforation in the oropharynx or proximal esophagus can cause neck swelling, tenderness, erythema, or cervical crepitus. Patients with a perforation in the mid or distal esophagus can present with severe retrosternal chest and/or upper abdominal pain, tachypnea, dyspnea, cyanosis, fever, and shock. Patients with an intra-abdominal perforation often report epigastric pain that may radiate to the shoulder. Patients may also report back pain and an inability to lie supine or present with an acute (surgical) abdomen with rebound, guarding, tachycardia, hypotension, and fever. As with intrathoracic perforation, sepsis can rapidly develop within hours of presentation.
Obstruction - The symptoms most commonly associated with acute small bowel obstruction are nausea, vomiting, cramping abdominal pain, and obstipation (i.e., inability to pass flatus or stool).
Fistula - Impaction of a foreign body in the esophagus can cause ulceration due to tissue necrosis and if prolonged can result in the formation of an aortoesophageal or trachea-esophageal fistula. Aortoenteric fistulas are rare; gastrointestinal bleeding is the most common presentation. The severity of bleeding ranges from a minor hemorrhage to massive, life-threatening bleeding or overt rapid exsanguination. Patients with a tracheoesophageal fistula usually present with cough, cyanosis, and dysphagia, choking, and vomiting. "
The patient in this case had a foreign body sensation but did not have complication of an ingested foreign body such as perforation, obstruction, aortoesophageal fistula formation, or tracheoesophageal fistula formation. She remained hemodynamically stable without respiratory distress the entire time in the hospital. There was ultimately no foreign body identified on the endoscope. Although the patient had needs best addressed in the hospital setting the monitoring, diagnostic workup and therapeutic interventions prescribed could have been safely administered at a lower level of care. Therefore, medical necessity of admission has not been established.