Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Allergies
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male child with medical history significant for asthma. He ate some mixed nuts at school, after which he developed throat discomfort, dyspnea, pruritic rash, and dysphagia. He was seen by his pediatrician, where he was treated with Benadryl and IM (intramuscular) epinephrine. He was then referred to the ED (emergency department) via EMS (emergency medical services).

Upon arrival to the ED (emergency department), the patient reportedly was feeling better. Vital signs included temperature 37.2, heart rate 142, respiratory rate 28, and blood pressure 121/82. Examination was significant for mild edema of the uvula and pharynx, mild tongue edema, enlarged (3+) tonsils, speaking and swallowing without difficulty, tachycardia, clear lungs, benign abdomen, hives, redness of the face/trunk/extremities, and non-focal neurologic exam. He was treated with a normal saline bolus, parenteral Benadryl, parenteral dexamethasone, and parenteral famotidine.

The patient was monitored and re-evaluated multiple times (approximately every 30 to 60 minutes), and eventually referred for admission because of persistent oropharyngeal edema and hoarseness. Admission orders included continuous cardiorespiratory monitoring, parenteral Benadryl every six hours, parenteral famotidine daily, IV (intravenous) fluids, screening labs, and plans for additional steroids the next day.

The following day, the patient was feeling fine without complaints and with near-resolution of throat swelling. Screening labs were unremarkable. He was subsequently deemed stable for discharge.

No, the Inpatient admission was not medically necessary.

Anaphylaxis is a life-threatening hypersensitivity reaction to something in the environment. Onset is sudden and typically dramatic, with respiratory, skin, and gastrointestinal manifestations. There are multiple triggers, including foods, insect stings, and medications. Foods are the most common triggers in the pediatric population. Because anaphylaxis is a medical emergency, treatment must be rapid. Current guidelines agree that epinephrine is the first medication of choice because it is the only medication shown to reduce hospitalization and death. Second line treatments include antihistamines (H1 and H2) and glucocorticoids. Because symptoms may return as epinephrine is metabolized by the body, it is important to monitor patients depending on risk stratification. For standard risk patients, monitoring for three or four hours in the ED (emergency department) should be sufficient. For medium risk patients, those with history of asthma, mild wheezing upon presentation, slow resolution of symptoms, a longer period of observation is appropriate, six to eight hours. For high risk patients, those that have received two or more doses of epinephrine, that present with moderate to severe wheezing, hypotension, pharyngeal edema, or worsening of symptoms, hospitalization is appropriate.

This male child with history of asthma presented with oropharyngeal edema and urticaria after having eaten mixed nuts (no history of peanut allergy). He responded well to standard aggressive treatment in the ED (emergency department), but was admitted because of persistent uvular and pharyngeal edema and significantly enlarged tonsils. As a moderately high risk patient, monitoring in the hospital was reasonable and medically necessary. However, he was overall hemodynamically stable. He received only one dose of epinephrine, with no airway compromise. He did not require acute patient admission. He could have been safely managed at a lower level of care, such as observation.