Appeal type: Medical necessity
Decision: Overturned

Diagnosis: COVID 19
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

This is a female patient with a history of interstitial hypertension, hypercholesterolemia, localized scleroderma, interstitial lung disease, fibromyalgia, gastroesophageal reflux disease, and endometriosis. She was diagnosed with coronavirus 2019 (COVID-19) and started on Paxlovid, which was prescribed for a 5-day course. However, despite only having one day left of the medication, she reported difficulty breathing. The patient denied a fever, nausea, vomiting, diarrhea, chest pain, or abdominal pain.
During the physical exam, the patient was calm and cooperative, with no acute distress. The respiratory exam showed clear bilateral breath sounds with no audible wheeze, rhonchi, or rales. The cardiac exam showed regular rate and rhythm with S1-S2 and no audible murmur, click, or rub. The abdomen was soft, bowel sounds were positive, and there was no palpable mass or pain with palpation. 
A computed tomography (CT) angiogram of the chest showed no evidence of pulmonary embolism but demonstrated mild bibasilar atelectasis and scarring. The patient was admitted to the hospital with a COVID-19 infection, hypertension, and gastroesophageal reflux disease (GERD). She received treatment with Remdesivir and Decadron for her persistent COVID-19 infection, continued her home regimen of medications for hypertension, and continued taking omeprazole for her GERD.
The patient responded well to treatment, with improvement in the dyspnea and decreased supplemental oxygen requirements from 4 liters (L) to 2 L per minute. She was deemed medically stable for discharge. At issue is the medical necessity of an inpatient stay.

The inpatient admission was medically necessary. The indications for admission at the acute inpatient level of care for patients with COVID-19 infection may vary depending on the severity of the disease and the patient's underlying health conditions. In general, patients with moderate to severe COVID-19 symptoms, such as significant respiratory distress, hypoxemia (low oxygen saturation), or evidence of multiorgan dysfunction, may require hospitalization. Other factors that may necessitate acute inpatient care include the patient's age, comorbidities, and overall clinical status. Patients with advanced age, immunosuppression, chronic medical conditions (e.g., diabetes, heart disease, lung disease), or obesity may be at higher risk for severe COVID-19 illness and may require hospitalization even with mild or moderate symptoms. Patients who are unable to maintain adequate oxygen saturation levels despite oxygen supplementation, or who require mechanical ventilation, may require admission to the intensive care unit (ICU). Additionally, patients who develop complications such as bacterial superinfection, acute respiratory distress syndrome (ARDS), or thromboembolism may also require acute inpatient care. Ultimately, the decision to admit a patient with COVID-19 to the acute inpatient level of care is based on a careful assessment of the patient's clinical status, risk factors, and potential for disease progression.
In this particular case, the patient had interstitial lung disease, which was associated with chronic respiratory failure with hypoxia requiring continuous administration of supplemental oxygen. The patient complained of persistent dyspnea despite taking Paxlovid for 4 days after she was diagnosed with a COVID-19 infection. The patient was rightfully placed on a regimen of medications including Remdesivir and Decadron administered intravenously. The patient also required close monitoring of her respiratory status in the setting of acute superimposed on chronic respiratory failure.
Even though the patient's symptoms were classified as mild to moderate, the underlying chronic lung disease and lack of significant improvement after taking Paxlovid for 4 days were concerning factors.