Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pneumothorax
Treatment: Inpatient hospital admission
The insurer denied coverage for inpatient hospital admission
The denial is overturned

This case involves an adult patient with an extensive pulmonary history which includes asthma and multiple intubations as a child. Records noted the patient had right greater than left thoracic outlet syndrome that was status post right first rib resection with decompression of brachial plexus. When the patient presented to the emergency department (ED), the patient reported a sudden onset of right-sided chest pain with shortness of breath. On physical examination, the patient's vital signs were stable with blood pressure 104/67, pulse 60, respirations 18, and pulse oximetry of 100% (percent). The patient was alert and oriented x (times) 3 with some increased work of breathing, but no respiratory distress noted. The patient was placed on 9 liters of oxygen via nonrebreather mask with a pulse oximetry at 98%.  Laboratory testing was unremarkable. Chest x-rays showed evidence of right apical pneumothorax. The patient was admitted for further management with claims that certain components of the treatment plan can only be accomplished in an inpatient setting, and the patient had a new requirement of supplemental oxygen to maintain adequate saturation. The patient underwent chest tube placement with percutaneously placed a pigtail catheter inserted while the patient was in the ED. Repeat chest x-rays showed moderate right pneumothorax with right basilar compressive atelectasis, and trace right pleural effusion. There was associated postsurgical subcutaneous emphysema along the right lateral chest wall. On removal of the chest tube, chest x-ray showed no pneumothorax. The patient was subsequently discharged once deemed medically stable. 

The patient received a notice of adverse determination regarding the inpatient stay, which failed to provide coverage for the services rendered with claims that the full hospital admission was not medically necessary. The claim was that the plan's clinical criteria consider a full hospital admission medically necessary when severe problems exist. The information sent did not show the patient had a severe problem. An appeal was submitted stating that the hospital admission was warranted and appropriate.  

The Milliman Care Guidelines state that the clinical indications for admission to inpatient care for individuals with a pneumothorax must include that the patient has 1 or more of the following: pneumothorax caused by associated lung disease such as chronic obstructive pulmonary disease, bullous or cystic lung diseases, or lung cancer, traumatic pneumothorax that is moderate or large (chest wall distance is greater than or equal to 1.5 centimeters) or expanding, when there is a tension pneumothorax, hypoxemia, altered mental status, pneumothorax exacerbating significant comorbidities such as heart failure, dyspnea or tachypnea that persists despite observation care and requires needle aspiration, and identified infection that requires inpatient management, severe pain requiring acute inpatient management, or when there is a need for intervention for the pneumothorax beyond observation care timeframe to include chest tube placement with active evacuation. The information provided for the review noted that the patient had confirmation of a right apical pneumothorax on chest x-ray. The patient required chest tube placement to relieve the pressure, and to help reduce discomfort. The goal length of stay for patients with a pneumothorax requiring further treatment is 2 days. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for full hospital admission is substantiated.