Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Swollen tongue, chest tightness, difficulty swallowing
Treatment:  Inpatient admission

The inpatient admission was medically necessary.

It was medically necessary for this patient to remain in the hospital secondary to discharge planning and monitoring of patient airway. 

This is a patient who presented with tongue swelling and difficulty breathing, which was suspicious for angioedema or allergic reaction as an effect of a medication.  Hence, prompt therapy with diphenhydramine, steroids, and famotidine had to be initiated.  The patient had a history of mental illness and was admitted from the psychiatry department, which adds a layer of complication, since his psychiatric illness makes him a less reliable historian, and makes it so that he requires much closer monitoring.  The patient was closely watched, and had continued tongue edema, which necessitated increased and repeated IV steroid dosing.  His symptoms resolved, and he was able to be transitioned to an outpatient level of care. 

By admitting the patient to an inpatient level of care, a more viable follow-up treatment plan could be formulated, and morbidity and mortality could be prevented.  All of this could not have been done in the outpatient setting.  There was no way to manage this patient other than to admit him to a medical inpatient level of care for close monitoring and treatment.  The American Academy of Emergency Medicine (AAEM) recommends intensive care unit (ICU) admission for patients with tongue edema, since this may be a precursor to life threatening laryngeal edema. 

The patient was at constant risk of airway loss, so that his treatment team was concerned enough to keep intubation equipment at bedside.  The patient was admitted to the step down unit for the level of nursing care required to monitor him.  He required serial IV dosing of steroids.  None of this can be done in the psychiatric department, and the only other option that the health plan denial recommends is to discharge the patient to home, which would not be in line with standards of care. 

The patient did well, without any sign of critical illness.  However, this does not negate the necessity of this admission for close monitoring.  Hence the physician's decision making for this patient at the time of admission was consistent with the patient's acute presenting signs and symptoms, the concern for airway edema and concern for respiratory failure. 

The patient was managed for angioedema and then needed transfer to a facility that could care for him further for his addiction disorder.  There was not space for this patient; therefore, the patient was kept in the hospital until appropriate placement could be found while monitoring his airway and also his addiction disorder. 

According to literature: 
Discharge planning is the development of an individualized discharge plan for the patient, prior to leaving the hospital, to ensure that patients are discharged at an appropriate time and with provision of adequate post-discharge services.  Such planning is a mandatory part of hospital accreditation.

Discharge planning is a complex process that seeks to determine the appropriate level of services required by the patient and then matches the patient to an appropriate site of care.  This process ideally begins at the start of the hospitalization.  The hospital case manager should be involved as soon as it is clear that the patient will require services at home or transfer to an alternative level of care.

In this case, it required time to manage this patient's discharge in order to prevent further complications. 

Therefore, the inpatient admission was medically necessary.