Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory System.
Treatment: Inpatient Hospital.
The insurer denied Inpatient Stay.
The denial is upheld.

This patient is a gravida (G) 1 para (P) 0 who presented at 28-2/7 weeks gestational age with a chief complaint of flu like symptoms. The day prior, the patient was triaged as a non-urgent patient and stated that she was sent to labor and delivery (L&D) as her physician sent here there because she had the flu. The patient had no history of coronavirus 19 (COVID19). She had an estimated date of confinement (EDC) approximately 3 months after presentation. She reported that she had tested positive for flu in the office on that date (day prior to presentation). She was positive for influenza (FLU)-A and negative for COVID-19. She had tachycardia despite intravenous (IV) fluid resuscitation and denied chest pain or shortness of breath. She was confirmed positive by an in-house test. The patient had no pregnancy complications but endorsed congestion. Her review of systems was positive for fever and chills with cough. She had a prior history of excision of left labia minora skin tag. She has no significant medical history. She was a non-smoker. Exam noted that she was in no acute distress. She had clear breath sounds bilaterally and positive upper respiratory congestion. She had a regular rate and rhythm and was negative for tachycardia on exam. Fetal heart rate monitoring was reassuring and Category I. She was started on oral Tamiflu 75 milligrams (mg) every 12 hours, azithromycin orally and Tylenol 650 every 6 hours. She received a Lactated Ringers (LR) IV bolus of 500 cubic centimeters (cc) and had ongoing intravenous (IV) fluids at 100 milliliters per hour (mL/hr). Chest x-ray was ordered, and blood and urine cultures were sent. A biophysical profile (BPP) was performed and was also 8/8 and reassuring. The patient had a temperature (T) maximum of 38.1 Fahrenheit (F) and heart rate of 145. She had a respiratory rate of 21 with a peripheral capillary oxygen saturation (SpO2) of 98% on room air. The patient also had a Medical Intensive Care Unit (MICU) consultation and they agreed with the plan of care. Labs noted the patient to have a white blood cell (WBC) count of 11.2 with hemoglobin (Hgb) 11.0 and Hematocrit (HCT) of 33.6%. The patient had a normal basic metabolic panel. The respiratory panel was noted to be positive for Influenza A. The chest X-ray was normal. Fetal ultrasound was normal at the 50%ile at 1283 grams or 2 pounds 13 ounces. The patient was discharged. Follow-up was scheduled in the outpatient setting. The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld. 

Based upon a review of the medical records, the peer reviewed literature and the InterQual criteria - Acute Adult Infection: General, there would have been no medical necessity for admission to inpatient level of care for this patient. In this case, the patient was noted to have influenza and after IV fluids was noted to have normalization of heart rate by administration of IV fluids by exam without tachycardia. The InterQual guideline was reviewed in concert with the records and the patient did not have a white blood cell count that was elevated to the degree for consideration of acute inpatient admission. The patient was noted to have a viral respiratory infection but did not have an abnormal chest X-ray or oxygen needs. Fetal testing was reassuring. Fetal growth and biophysical profile (BPP) were normal. The patient was on oral azithromycin and Tamiflu. Thus, the patient would not meet criteria for admission to acute inpatient level of care in this case.
In this case, there was no evidence of fetal compromise, and no interventions were needed on behalf of the fetal condition as IV fluids and Tylenol treated the fever. There was no abnormal fetal testing reported. The pregnant patient in this case did not require monitoring for any severe respiratory/pulmonary disease. In this case, the patient lacked any signs of pulmonary disease on exam, by rapid respiratory rate, or by X-ray. Thus, there was no need for admission for pulmonary condition in this case.