Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory Allergies. 
Treatment: Inpatient admission. 
The health plan denied coverage for the inpatient admission. 
The determination is upheld. 

The patient is a child with a medical history significant for recently diagnosed mild-intermittent asthma who presented to the emergency department (ED) with an allergic reaction. 
Historically, his asthma exacerbations were associated with an itchy throat and full body rash. On the day of his presentation, he developed voice changes, a scratchy voice, diffuse urticaria, and vomiting. His vital signs included a temperature of 36.6 degrees Celsius, a heart rate of 107 beats per minute, 28 respirations per minute, and a blood pressure of 104/73 millimeters of mercury (mmHg). 
He was non-toxic in appearance, with no acute distress noted. He had moist mucous membranes, mild wheezing bilaterally, good air entry in the lungs, no retractions, a benign abdomen, scattered urticaria, and a non-focal neuro exam. He was diagnosed with acute severe anaphylaxis and treated with intramuscular (IM) Epinephrine, steroids, Famotidine, Benadryl, Zofran, a fluid bolus, and three nebulizer treatments. He continued to vomit in the ED, so he was given an additional dose of Epinephrine for rebound anaphylaxis and was admitted for further management. 
He was stable upon arrival to the floor. His admission orders included cardiorespiratory monitoring, albuterol, Benadryl, Zyrtec, and a social work consultation. He had recurrence of urticaria after lunch and was treated with Benadryl. Allergy consultation was sought, with recommendations to start routine Zyrtec, obtain respiratory allergy and seafood panels, and discharge with an EpiPen.
It was not clear if the child was experiencing viral infection, environmental allergies, or true anaphylaxis, but with recurrence of urticaria, he was monitored for a longer period of time. 
He remained stable for more than 24 hours, so was deemed stable for discharge. 

At issue is the medical necessity of the inpatient hospital stay. 

The health plan's determination of medical necessity is upheld in whole. 

The requested health service/treatment of inpatient hospital admission was not medically necessary. 
Anaphylaxis is a life-threatening hypersensitivity reaction. The onset is sudden and typically dramatic, with respiratory, skin, and gastrointestinal manifestations. There are multiple triggers, including foods, insect stings, and medications. 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 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 should be sufficient. For medium risk patients, (such as those with a history of asthma, mild wheezing upon presentation, or slow resolution of symptoms) a longer period of observation is appropriate, six to eight hours. For high-risk patients, (such as those that have received two or more doses of epinephrine or present with moderate to severe wheezing, hypotension, pharyngeal edema, or worsening of symptoms) hospitalization is appropriate. 
This child presented with a several day history of cold symptoms, was treated in the ED, then continued to have symptoms raising concern for rebound. 
He had recurrence of urticaria after a meal and was treated with Benadryl, but was otherwise hemodynamically stable with no evidence of breathing difficulties, no further vomiting, and no lip or tongue swelling. While it was reasonable to observe him in the hospital for resolution of symptoms, he did not require acute inpatient admission and could have been safely managed at an alternative level of care.