Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Exertional hypoxia
Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient initially presented to the emergency department with concerns of chest pain, cough, and weakness. Pertinent history included a coronavirus disease 2019 (COVID-19) diagnosis, multiple sclerosis, and asthma. Initial vital signs revealed a temperature of 98.5 degrees Fahrenheit (F), heart rate (HR) 105, blood pressure (BP) 103/70, respiratory rate (RR) 16, and peripheral capillary oxygen saturation (SpO2) 96% on room air (92% on exertion). Initial examination documented the patient as alert and oriented without respiratory distress. Initial laboratory testing revealed a normal white blood cell count (WBC), potassium (K) 3.1, lactate 1.5. A COVID-19 test was positive. A chest radiograph revealed bilateral ground glass opacities. A computed tomography (CT) angiogram of the chest did not reveal an acute pulmonary embolism, but noted the bilateral ground glass opacities. The patient was admitted to the hospital with an impression of exertional hypoxia in the setting of COVID-19 pneumonia, chest discomfort due to gastroesophageal reflux disease (GERD), and weakness due to multiple sclerosis (MS) flare. The treatment plan included dexamethasone, oxygen supplementation, and neurology consultation. The patient felt improved. The peripheral capillary oxygen saturation (SpO2) was 95% on room air. A neurology consultation was obtained with an impression of relapsing and remitting multiple sclerosis (MS) with worsening fatigue. Recommendations included magnetic resonance imaging (MRI) of the brain and therapy services. The MRI of the brain did not reveal significant acute findings. The patient was discharged to home.
At issue is the medical necessity of an inpatient stay.

Based on the clinical documentation provided, evidence based literature and standards of care, acute inpatient level of care was not medically necessary for the entire admission. Evaluation and management could have been performed at a lower level of care.
Gandhi et al. note COVID-19 has a range of clinical manifestations, including cough, fever, myalgias, gastrointestinal symptoms, and anosmia. The diagnosis of COVID-19 is commonly made through detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) ribonucleic acid (RNA) by polymerase chain reaction (PCR) testing of a nasopharyngeal swab or other specimens, including saliva. Antigen tests are generally less sensitive than PCR tests but are less expensive and can be used at the point of care with rapid results. Evaluation and management of COVID-19 depend on the severity of the disease. Hallmarks of moderate disease are the presence of clinical or radiographic evidence of lower respiratory tract disease but with a blood oxygen saturation of 94% or higher while the patient is breathing ambient air. Patients who have mild illness usually recover at home, with supportive care and isolation. Patients who have moderate disease should be monitored closely and sometimes hospitalized. If there is clinical evidence of bacterial pneumonia, empirical antibacterial therapy is reasonable but should be stopped as soon as possible.[1]
In this particular situation, the patient presented with a cough and weakness followed by a diagnosis of viral pneumonia secondary to COVID-19. The initial peripheral capillary oxygen saturation (SpO2) was documented at 96% while breathing ambient air at rest and 92% with exertion. Treatment included dexamethasone and oxygen supplementation. Following observation care, clinical improvement was achieved and SpO2 returned at 95% on room air. No other issues or complications were documented.
Clinical indications for admission to inpatient care were not met. The patient did not have impending or actual respiratory arrest, severe airflow or ventilation abnormalities not responsive to emergency and observation care treatment, severe respiratory findings not responsive to emergency and observation care treatment (eg. hypoxemia, severe tachypnea, accessory muscle use, respiratory retractions).[2][3]