Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Allergic urticaria, Hypertension
Treatment: Inpatient hospital stay
The insurer denied coverage for an inpatient hospital stay.
The denial is overturned. 

This is a female patient with a history of urinary incontinence and hypertension who took the antibiotic Bactrim and was diagnosed afterwards with drug rash with eosinophilia and systemic symptoms (DRESS) syndrome, a drug reaction that can be devastating. She was admitted for management, treated with oral and topical medications, and then discharged. 

Per the American Academy of Allergy, Asthma & Immunology (2020), "Patients with DRESS can have a broad range of symptoms, which can include fever, rash, facial swelling, enlarged lymph nodes and kidney or liver injury. Most patients with DRESS will have an abnormal level of blood cells found in their blood tests, which are called eosinophils. Eosinophils are cells associated with allergic diseases, and, when they are present in large numbers, can cause organ damage. The rash can present in a variety of different ways, commonly as a red rash, and can be present anywhere on the skin, but will often start on the face and upper body. Although it is rare, other organs can also be inflamed due to DRESS. The most important step in treating DRESS is to stop the medication involved in the reaction, and sometimes, no further treatment is needed.  Topical steroids can be given to treat the rash. Often, however, further treatment is needed to protect the organs from damage, such as with steroids, which can be given either intravenously or orally. Treatment with steroids can be needed for weeks or even months, and lab work is monitored carefully during this time. The average time to recovery is six to nine weeks. Long term, most patients do well, although some patients can go on to develop autoimmune diseases so additional monitoring should be considered."

Wolfson, A. R., Zhou, L., Li, Y., Phadke, N. A., Chow, O. A., & Blumenthal, K. G. (2019), "Among 3,162,562 patients with 3,319,387 million allergy entries, 538 reactions matched keywords, and 69 were DRESS cases (prevalence 2.18 per 100,000).  DRESS patients had liver (42%) or renal (42%) injury; 11 (16%) had both liver and renal injury.  Primary drug culprits were antibiotics (74%) (vancomycin [39%], beta-lactams [23%], fluoroquinolones [4%], tetracyclines [4%], and sulfonamides [3%]) and anticonvulsants (20%).  Of 65(94%) hospitalized DRESS patients, 43 (66%) were hospitalized for DRESS syndrome management with median length of stay 9 days [IQR, 617 days]."

Choudhary, S., McLeod, M., Torchia, D., & Romanelli, P. (2013), "a wide variety of cutaneous findings were observed; notably, diffuse maculopapular inflammatory reactions (most common), erythroderma, SJS/TEN, erythema multiforme (EM), and pruritic eruptions. Eosinophilia was the most frequently occurring hematological abnormality (>50% of the cases)."      

The patient had a drug rash and the admitting team did not know the severity, which can occur over 24 hours, and made the decision to admit. The patient's eosinophils were elevated, which suggests a drug reaction. The delay of onset of 9 days after starting is consistent with a slight delay onset drug reaction. DRESS syndrome is a serious condition that can lead to liver failure. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.

The carrier's denial of coverage for the inpatient hospital stay is overturned. The medical necessity is substantiated.