Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory System. Treatment: Inpatient Hospital. The insurer denied Inpatient Stay. The denial is upheld. 

The patient is a girl with a past medical history significant for seasonal allergies who presented to the emergency department for evaluation of a sore throat. It was reported that the patient started to have a fever and sore throat. She presented to the emergency department, and at that time was noted to have right tonsillar hypertrophy and uvular deviation. Rapid Streptococcus test was positive. The ear, nose, and throat (ENT) service was consulted, and the patient was diagnosed with tonsillitis. The patient was discharged from the hospital with Augmentin. The patient's mother stated that she checked her tonsils regularly and was under the impression that the swelling became worse. The patient's mother stated that the patient had minimal relief of the throat pain despite using Tylenol, Motrin, and saltwater gargles. Because of the pain, the patient was unable to eat and only drank fluids. The patient was still able to swallow her secretions and had normal urinary output. The patient's mother denied difficulties breathing while awake. The patient's mother denied lethargy, syncope, seizure, cough, congestion, rhinorrhea, wheezing, vomiting, diarrhea, swelling in the extremities, or skin rash.

At the time of the initial evaluation, the patient's temperature was 98.6 F, blood pressure was 106/74, pulse rate was 139 beats per minute (bpm), respiratory rate was 20 breaths/minute, and oxygen saturation was 100% on room air.

The patient was sitting in an upright position in a chair, playing on a tablet. She looked nontoxic. On the head, eyes, ears, neck, throat (HEENT) exam, there was significant right tonsillar hypertrophy with exudate and uvular deviation to the right. There was tonsillar and right anterior cervical lymphadenopathy. Her lungs were clear to auscultation without wheezes, rales, or rhonchi. The rest of the exam was unremarkable. The patient was admitted to the hospital with tonsillar swelling.
The patient was admitted to the hospital with a diagnosis of bacterial tonsillopharyngitis and a marked decrease in oral intake. In the hospital, the patient was managed with intravenous Unasyn, intravenous fluids, Tylenol, and Motrin. Within the first 24 hours of admission, her oral intake considerably improved, and she remained afebrile.
At issue is the medical necessity of Inpatient Stay.

The health plan's determination of medical necessity is upheld in whole.

The requested health service/treatment of Inpatient Stay is not medically necessary for this patient.
The patient presented to the hospital with tonsillopharyngitis. Tonsillopharyngitis is usually viral, most often caused by the common cold viruses (adenovirus, rhinovirus, influenza, coronavirus, and respiratory syncytial virus). In about 30% of patients, the cause is bacterial. Group A beta-hemolytic streptococcus (GABHS) is most common. At the time of the presentation, the patient was afebrile, and had a normal blood pressure. She was initially tachycardic, but the tachycardia improved within a short period of time. At the time of the initial evaluation, the patient was not in any distress. She had a normal respiratory rate and normal oxygen saturation. There was no strider or wheezing reported. It was indicated in the notes that the patient's oral intake considerably improved within the first 24 hours of hospitalization. During the hospitalization, the patient remained afebrile and hemodynamically stable, to the point that she was discharged home on the second day after the day of admission.
Overall, this young patient remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care.
Therefore, the requested health service/treatment of Inpatient Stay is not medically necessary for this patient.