Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malaria.
Treatment: Inpatient Hospital Admission.
The insurer denied: Inpatient Hospital Admission.
The denial is upheld.

The patient is an adult female with no known past medical history with recent travel to Nigeria and stayed there for six weeks. The patient did not take any malaria prophylaxis during her stay there and she also ate and drink local food. The patient returned to New York about one week ago and presented to the emergency room with complaints of generalized weakness, aches and pain, fever, chills, pain in the stomach - abdomen, dark urine and vomiting once (x1). The patient had obtained chloroquine for three days (she obtained that from a friend) but did not have any improvement and she presented to the emergency room. In the emergency room, the patient's temperature was 100.3 Fahrenheit (F), and the patient had tachycardia. Her electrocardiogram (EKG) showed sinus tachycardia and chest x-ray was negative for pulmonary pathology. The patient was given intravenous fluids and ceftriaxone for one dose in the emergency room. The patient was placed on observation pending malaria prep result, which was found to be positive. The patient was started on Coartem. The patient was evaluated by Infectious Disease and further work up planned included blood cultures, Dengue / Chikungunya polymerase chain reaction (PCR) / serologies, Hepatitis B and C serology, peripheral smear for malaria for speciation and lower extremity Doppler. The patient continued to improve and was discharged on Day #4.

Medical necessity is not established for the inpatient hospital admission.

The patient was febrile on presentation and had symptoms and lab findings consistent with malaria. The patient also had tachycardia that was consistent with the diagnosis of malaria. The patient was initially admitted to observation status and did not have any findings on presentation to indicate a need for inpatient hospital stay. The patient's diagnosis was established, and treatment was already started for malaria. The patient was able to tolerate oral intake and did not have any lab abnormalities that required immediate treatment in a hospital setting. The patient's mental status was also maintained. In addition, the patient did not have medical history or baseline immune compromising conditions that would predispose her to be at risk for severe disease.
In general, hospitalization for malaria is not routinely advised. Inpatient care is recommended when a patient's symptoms, signs, imaging data, and labs suggest a moderate to severe illness. Additional factors to take into consideration are the presence of co-morbid conditions, the relative instability of such co-morbid conditions, and the risk of deterioration. The judgement of severity and risk is based on assessment of medical factors in the context of known and generally accepted medical knowledge prevalent. Moderate to high intensity interventions that are required for evaluation and management of the condition also justify an inpatient level of care. With relative clinical stability, lack of comorbid unstable conditions, and lack of intractable symptoms, ongoing inpatient care was not medically necessary.