Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pneumomediastinum
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.
The patient is a male teen. He presented to the emergency department (ED) because of sudden onset neck pain gradually radiating down to his chest, as well as some pain with swallowing.
He denied any difficulty breathing or history of asthma.
The patient's vital signs included temperature 37.3, heart rate 82, respiratory rate
15, blood pressure 100/60, and pain rated 7/10. Examination was significant for no
distress, moist mucous membranes, no neck stiffness, mild muscular tightness in
the neck region, no crepitus initially, regular heart rate and rhythm, clear lungs,
benign abdomen, tenderness to palpation of the anterior chest wall, and non-focal
neurologic exam. The initial differential diagnosis was gastroesophageal reflux
versus musculoskeletal chest pain.
A chest x-ray was ordered, and the patient was treated with ibuprofen and Maalox.
Electrocardiogram was not suggestive of ischemia or infarct. Laboratory evaluation
was essentially unremarkable. The chest x-ray revealed pneumomediastinum
without evidence of pneumothorax. There was a large amount of subcutaneous air
within the left supraclavicular region and left axilla as well as a small amount of air
in the right clavicular region. Cardiothoracic surgery (CT) Surgery was consulted with recommendations to obtain computed tomography (CT) lung with contrast and computed tomography (CT) neck soft tissue with contrast, as well as likely
admission. CT lung revealed moderate pneumomediastinum with no pneumothorax, subcutaneous emphysema within the neck and clavicular regions and the left axilla.
CT neck soft tissue revealed pneumomediastinum with subcutaneous gas within
the bilateral clavicular spaces and left axilla, within the retropharyngeal space and
left masticator space, within the bilateral carotid spaces.

The patient was admitted for observation of pneumomediastinum. He did well, with
no increase in symptoms. No invasive procedures were recommended or planned.
The pneumomediastinum was considered to be spontaneous, with stable and
possible slight interval decrease on chest x-ray obtained. He was deemed stable for
discharge, with follow-up in a week.
No, the Inpatient admission was not medically necessary.
Pneumomediastinum indicates the presence of free air within the mediastinum. This
condition is extremely rare in the pediatric population with some association with
excessive coughing. It is overall considered to be a benign condition. While most
patients are hospitalized for observation and pain management, ambulatory
management may be considered in individual cases. Long-term follow-up of these
patients shows fairly rapid resolution and no increase in recurrence.
In this patient's case, he presented with neck and chest pain and was found to have
extensive pneumomediastinum on x-ray and computed tomography (CT) imaging. Consistent with the current standard of care, he was hospitalized for 24-hour observation. Per Cardiothoracic (CT) Surgery, there was no indication for surgical intervention. While it was not unreasonable to monitor him in the hospital for progression of symptoms, progression of air leak, and cardiopulmonary decompensation, he remained overall hemodynamically stable with no evidence of progression of symptoms or air leak. He did not require acute inpatient management. He could have been safely managed at a lower level of care.