Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer

The patient is a 72-year-old male with a medical history of heart and kidney transplant. He presented to the emergency department with complaints of worsening cough for three weeks with shortness of breath and headache. He was admitted on 1/26/17 to an acute inpatient level of care. He was treated for acute on chronic diastolic dysfunction and chronic eosinophilic pneumonia with empiric antibiotics. His symptoms improved, and he remained stable. He developed headache with associated scalp pain. The etiology of the pain was unclear, as the patient had a complex wound on the scalp associated with squamous cell cancer. Eventually, he developed an associated rash and was treated effectively for a Zoster infection with intravenous acyclovir from 2/02/17 through 2/06/17. On 2/06/17, the documentation notes that the lesions were crusted, intravenous (IV) acyclovir was discontinued, and the patient was started on oral Valtrex for seven additional days. On 2/07/17, the patient was discharged in stable condition to a skilled nursing facility for further care. The Health Insurer has denied reimbursement for inpatient hospital services provided from dates of services 2/05/17 through 2/07/17. Per the Health Insurer, the services at issue were not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. Antiviral therapy has been shown to decrease progression and dissemination of acute herpes zoster in immunocompromised patients. Intravenous acyclovir remains the drug of choice for patients with evidence of disseminated disease or visceral organ involvement, ophthalmic involvement, advanced human immunodeficiency virus/acquired immune deficiency syndrome, and transplant recipients who have recently undergone transplantation or are being treated for rejection. This patient was admitted to the hospital from 1/26/17 through 2/07/17. He is considered immunocompromised due to taking medications for a heart transplant that are immunosuppressive.  He was admitted due to a cough with chest pain and headache. He was started on IV acyclovir for a Zoster infection. He was tolerating this medication well, with slow improvement in pain and the rash. By 2/05/17, the patients pain was controlled with oral medication. There is no documentation that the patient had a fever or any intolerance to the medication. On 2/06/17, he continued to improve, the lesions were noted as being crusted over, and the treatment was changed to oral antiviral medications.  In this case, the documentation does not support the continued need for acute inpatient hospitalization from 2/05/17 through 2/07/17. The patients pain was controlled.  The eye specialist had determined that the infection did not involve the eye. The rash was improving, and there was no documentation demonstrating why he could not be transitioned to oral antiviral medication on 2/05/17 and discharged to a lower level of care. All told, inpatient hospital services provided from dates of services 2/05/17 through 2/07/17 were not medically necessary for the treatment of this patient. Therefore, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.