Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin Disorders/Rash.
Treatment: Inpatient Hospital.
The health plan denied the requested inpatient stay as not medically necessary. 
The health plan's determination is upheld.

The patient is a female child with a medical history significant for autism who was taken to the emergency department (ED) for evaluation of lip swelling and a generalized rash. She had been treated at home with Ibuprofen for a tactile fever and cough. She had been given a medication that had not been given prior and had also eaten several foods that she had never eaten before. She had no difficulty breathing, no wheezing, no nausea or vomiting. Vital signs included a temperature of 98.2F., a heart rate of 100 beats per minute (bpm), and a respiratory rate of 20/minute. An examination was significant for no acute distress, appropriate interactions, scattered hives to the left side of her neck and forehead and right upper extremity and trunk, symmetric upper and lower lip edema, clear lungs, moist mucous membranes, benign abdomen, and a non-focal neurologic exam. The patient was treated with intramuscular Epinephrine twice, intramuscular Benadryl, and intramuscular Dexamethasone.  She remained stable while in the ED with no respiratory difficulties. Admission orders included neurochecks every hour, vital signs every hour, continuous pulse oximetry, regular diet as tolerated, anaphylaxis education, plan for an EpiPen prescription, and an outpatient allergy consultation. The following day, with no acute events overnight and resolution of the urticarial rash and lip swelling, the patient was deemed stable for discharge. 
At issue is the medical necessity for the inpatient stay.

The health plan's determination of medical necessity is upheld, in whole.

The patient could have been safely managed at an alternate level of care.
Anaphylaxis 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 (H1 and H2) and glucocorticoids. For standard risk patients, monitoring for three or four hours in the ED should be sufficient. For medium risk patients, those with a 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, who present with moderate to severe wheezing, hypotension, pharyngeal edema, or worsening of symptoms, hospitalization is appropriate.
This child presented with lip swelling and an urticarial rash after eating new foods and being treated with new over-the-counter medication. She had no gastrointestinal symptoms or respiratory symptoms. She was treated with two doses of intramuscular Epinephrine in the ED, along with Benadryl and Dexamethasone. Because the patient required two doses of Epinephrine, she was admitted for ongoing observation. While it was reasonable and appropriate to continue monitoring this child in the hospital for resolution or worsening of her anaphylactic-like reaction, she was overall hemodynamically stable with no respiratory distress, there was no threat to her airway, and no gastrointestinal symptoms. She did not require an acute inpatient admission and she could have been safely and appropriately managed at an alternate level of care.