Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Skin Disorders-Other- Swelling. 
Treatment: Inpatient hospital admission. 

The health plan denied the inpatient hospital admission as not medically necessary. 
The reviewer has overturned in whole the health plan's determination. 

This patient has a medical history significant for failure to thrive, atopy, and eosinophilic esophagitis that was taken to the emergency department (ED) via Emergency Medical Services (EMS) because of an allergic reaction. Approximately thirty minutes after eating kidney beans, something he had eaten many times previously, he developed lip and eyelid swelling. He was treated with Benadryl without improvement, and EMS was contacted. En route to the ED he was given a dose of intramuscular (IM) epinephrine. The family had an EpiPen but did not know how to use it. Vital signs included temperature 97.4, heart rate 181, respiratory rate 38 with 100% saturation in room air, and blood pressure 113/56. Examination was significant for excoriated areas on the face with redness on bilateral cheeks, eczema on the legs and arms, some red lesions on the chest, hypopigmentation on the back and legs, moist mucous membranes, multiple marks of erythematous raised red lesions on the cheeks bilaterally, no wheezing, no signs of altered mental status. He received a total of three doses of IM epinephrine, famotidine, normal saline bolus, and dexamethasone. Laboratory evaluation was overall unremarkable (leukocytosis not unexpected following parenteral steroids). He had one episode of vomiting in the ED but was otherwise stable. He was admitted for observation following anaphylaxis and for EpiPen education. He remained afebrile with no signs of respiratory distress. His behavior returned to baseline, as did his appearance. Following appropriate parent education, he was deemed stable for discharge home. 

Anaphylaxis is a life-threatening hypersensitivity reaction to something in the environment. Onset is sudden and typically dramatic, with respiratory, skin, and gastrointestinal manifestations. There are multiple triggers, including foods, insect stings, and medications. Foods are the most common triggers in the pediatric population. 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 (histamine (H)1 and H2) 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, those with history of asthma, mild wheezing upon presentation, slow resolution of symptoms, a longer period of observation is appropriate, six to eight hours. For high-risk patients, those that have received two or more doses of epinephrine, that present with moderate to severe wheezing, hypotension, pharyngeal edema, or worsening of symptoms, hospitalization is appropriate. 

This child presented to the ED following consumption of kidney beans, a food he had eaten multiple times before without difficulty, with swelling of the eyelids and lips as well as vomiting. He was treated with IM epinephrine, requiring a total of three doses due to rebound erythema and swelling. He also received the anaphylaxis cocktail with dexamethasone and Benadryl, famotidine, and parenteral fluids. Because of the severity of his symptoms, the recurrence of symptoms despite appropriate care in the ED, and his medical history with restricted diet, it was medically necessary and appropriate to admit to inpatient level of care. Lower level of care would not have been appropriate in this case.