Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Stridor

Treatment: Inpatient Hospital Admission

The insurer denied coverage for inpatient hospital admission.

The denial is upheld.

The patient is a female with history of diabetes mellitus, bacterial meningitis, seizures, and hypertension who presented to the hospital with complaint of stridor.  The patient had a prolonged hospitalization in the past with bacterial meningitis and respiratory failure and cardiac arrest.  The patient had a prolonged extubation and developed stridor and hoarseness due to that.  The patient was given dexamethasone at the facility, but continued to experience respiratory difficulty so was brought to the hospital. 

In the Emergency Department (ED), the patient's vital signs were: temperature of 97.9, heart rate of 108, respiratory rate of 18, blood pressure of 127/83, and oxygen saturation of 94%.  The patient was noted to be diaphoretic and in some distress with audible stridor and wheezing.  The patient was treated with intravenous (IV) steroids, racemic epinephrine, magnesium sulfate and DuoNeb.  The patient was also given oxygen supplementation.  The patient's condition responded well to treatment.  As per subsequent notes in the ED, the patient's vital signs were: temperature of 98.6, respiratory rate of 20, blood pressure of 102/59, heart rate of 101, and oxygen saturation of 97%.  The patient underwent diagnostic testing which revealed white blood cell count of 7.3K, hemoglobin of 10.1, and the patient's lactate, troponin and electrolytes were all within normal limits (WNL).  The patient's chest X-ray showed no acute infiltrates.  The patient's computed tomography (CT) scan of the neck revealed narrowing of the upper part of the trachea below the glottis and distension of supraglottic airways.  The patient's CT angiography (CTA) was negative for pulmonary embolism (PE); some scarring was noted.  The patient was subsequently admitted to the hospital.  As per History & Physical (H&P), the patient was afebrile and hemodynamically (HD) stable, in no acute distress.  The patient had audible stridor but no increased work of breathing.  The patient was alert and oriented, and her lungs were clear to auscultation.  The patient was seen by the Ear Nose & Throat (ENT) specialist who described that the patient was not in acute distress.  The patient was afebrile and HD stable.  The patient underwent laryngoscopy which revealed that the patient's cords were moving normally; no airway abnormality was detected.

Based on the review of the medical record and literature, inpatient hospital admission was not medically necessary for this patient.  The patient remained stable after admission.  The patient was treated with steroids and bronchodilators.  This patient had some tracheal stenosis and chronic stridor since her prolonged intubation in the past year.   There may have been some recent deterioration which responded to treatment in the ED with steroids, racemic epinephrine and bronchodilator (BD).  The patient was otherwise stable.  The patient could have been placed in observation status while diagnostic testing, treatment and consultations were obtained by the ENT.  The patient responded to treatment in the ED and remained clinically stable.  Evaluation of airway by ENT did not reveal any acute pathology.  The patient was discharged with outpatient follow-up by ENT.  This patient could have been discharged home after a period in observation status which could be up to 48 hours.  The patient could have been discharged on oral (PO) steroids and BD once deemed stable.  

The health plan acted reasonably, with sound medical judgment, and in the best interest of the patient.

The insurer's denial of coverage for the inpatient hospital admission should be upheld.  The medical necessity is not substantiated.