Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory failure
Treatment: inpatient admission
The insurer denied inpatient admission
The insurer's denial was upheld.

This case involves a female who was diagnosed with COVID along with reactive airway disease.  She was seen in the emergency room with complaints of a cough and shortness of breath. The emergency department triage notes noted that the patient's temperature was 99, heart rate 104, respirations 23, with pulse oximetry 95% on room air. The blood pressure was slightly elevated at 132/91. The assessment indicated that she had an open and patent airway with tachypneic breathing, wheezes, but strong peripheral pulses with regular rhythm. The Glasgow Coma Scale was 15 and her primary reason for the visit was shortness of breath. The patient reported difficulty breathing from the night before, admitted to a productive cough and chest heaviness.  She was hospitalized for COVID 2 months prior and was not currently taking any medications.  The comments stated that the patient was in no acute distress and while she complained of shortness of breath, her respirations were even and unlabored. Chest x-rays showed no focal airspace opacity, pleural effusion, or pneumothorax. The document claimed that the patient had acute respiratory failure along with reactive airway disease with wheezing. She was subsequently admitted for trouble breathing, placed on oxygen, provided medications, and then discharged the following day. The patient received a notice of adverse determination regarding the inpatient admission with claims that she had no unstable vital signs or other significant findings warranting inpatient admission. An appeal stated that the admission was medically necessary because of the reactive airway disease exacerbation and acute respiratory failure.  This review pertains to the denial of coverage for the inpatient admission.

The healthcare plan acted reasonably and with sound medical judgment and in the best interest of the patient.

The Milliman Care Guidelines stated that clinical indications for admission to inpatient care for those individuals with reports of respiratory failure include when there is a new (acute) need for mechanical invasive or noninvasive ventilation, when the patient has severe respiratory distress such as severe tachypnea with respiratory rate greater than 30 breaths/min, severe hypoxemia with partial pressure of oxygen less than 50 mmHg (millimeters of mercury) on greater than 50% oxygen or partial pressure of oxygen to FIO2 (fraction of inspired oxygen) ratio less than 200, and the patient has a severe ventilation deficit. This is indicated by 1 or more of the following to include hypercarbia-induced respiratory acidosis, documented partial pressure of carbon dioxide increase greater than 5 mmHg from disease baseline, airflow measurements less than 25% of predicted, forced vital capacity less than 20 mL (milliliters)/kg (kilogram) of ideal body weight, or a 50% decrease in vital capacity from baseline, and for patients with airway obstruction or inadequate protection. Alternatives to admission include home care or a recovery facility. The information provided for the review did not support that the patient cannot be treated safely and effectively on an outpatient or observational basis. While she complained of shortness of breath and chest pain, her chest x-rays were normal, and vital signs were relatively unremarkable. Additionally, the emergency department report clearly stated that the patient was not in acute distress despite claims that she reportedly had acute respiratory failure. The evidence did not support this diagnosis and she did not satisfy the criteria for inpatient admission. As such, the inpatient admission was not medically necessary.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for the inpatient admission is not substantiated.