Appeal type: Medical necessity
Decision: Upheld



Diagnosis: Coronavirus (COVID) pneumonia
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a patient with an unremarkable medical history who presented with complaints of a cough, fever, chills, and generalized body aches, which started one day before her presentation. The patient was diagnosed with coronavirus 2019 (COVID-19) infection and reported that her mother also had COVID-19, and she likely contracted it from her. The cough was productive with pale yellow sputum, and she experienced associated symptoms of headache and nausea. The patient had received three doses of the Pfizer COVID-19 vaccine and had previously been infected with COVID-19 twice.
The cardiovascular examination revealed a regular heart rate and rhythm, with normal heart sounds and no murmurs, rubs, or gallops. The lung auscultation was clear, and the abdominal examination was unremarkable. The rest of the physical exam did not reveal significant abnormalities.
The patient was admitted with a diagnosis of coronavirus (COVID) pneumonia and received three doses of Paxlovid upon admission, along with three days of Remdesivir. Throughout the admission, her oxygen saturation remained stable, and her clinical condition improved. The urinalysis showed some red blood cells (RBCs), but the patient had no urinary tract infection symptoms at the time and no visible blood in the urine. As the patient remained afebrile and hemodynamically stable, she was transitioned. At issue is the medical necessity of an inpatient stay.

The hospital stay was not medically necessary for this patient at the acute inpatient level of care.
Based on the current standards of care, some people with coronavirus 2019 (COVID-19) infection should be admitted to the hospital at the acute inpatient level of care.
The following criteria for admission are:
- Respiratory Distress: Patients presenting with severe respiratory distress, including increased work of breathing, persistent hypoxemia (oxygen saturation less than [<] 90 percent [%] on room air), or signs of respiratory failure, should be considered for hospital admission. These patients may require supplemental oxygen or advanced respiratory support.
- Hemodynamic Instability: Patients with significant hemodynamic instability, such as persistent hypotension or signs of shock, should be admitted for close monitoring and potential hemodynamic support.
- High-Risk Populations: Certain patient populations have an increased risk of severe illness due to COVID-19. This includes older adults (especially those aged 65 years and above), individuals with underlying comorbidities (such as cardiovascular disease, chronic lung disease, diabetes, immunosuppression, or obesity), and those with compromised immune systems. Admitting these high-risk patients allows for closer observation and prompt intervention if their condition deteriorates.
- Significant Comorbidities: Patients with significant comorbidities that may complicate the course of COVID-19, such as uncontrolled diabetes, chronic kidney disease, or severe hypertension, may benefit from hospital admission for specialized care and management of these underlying conditions in the context of COVID-19.
-Need for Therapeutic Interventions: Patients who require specific therapeutic interventions that cannot be provided in an outpatient setting, such as intravenous antiviral therapy (e.g., remdesivir) or immunomodulator agents (e.g., tocilizumab), should be admitted to the hospital for the administration and monitoring of these treatments.
- Social Factors: In some cases, social factors should be taken into consideration when determining the need for hospital admission. Patients who lack appropriate home support, face challenges in adhering to isolation measures, or have limited access to healthcare resources may be candidates for hospital admission to ensure proper care and infection control.
The review of the medical records did not demonstrate that the patient had any of the circumstances listed above. She was young and had no significant underlying medical problems.
This patient had no signs of sepsis and normal oxygen saturation on room air. Therefore, admission seems to be the most appropriate, given the clinical circumstances. There was no compelling clinical reason why the patient could not have safely and appropriately received evaluation and treatment at the observation level of care with subsequent transition to outpatient care, rather than admission to an inpatient level of care.
Overall, this patient remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care.