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201912-123495

2020

Fidelis Care New York

Medicaid

Infectious Disease

Inpatient Hospital

Medical necessity

Upheld

Case Summary

Diagnosis: Influenza infection
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

The patient is an adult male with history of hypertension and hypercholesterolemia. He presented to the emergency room with shortness of breath (SOB). During the ER evaluation, the patient was found to be influenza A-positive. The patient had elevated D-dimer, as well as elevated BNP (brain natriuretic peptide). The CT-chest excluded pulmonary embolism but showed pleural effusions and cardiomegaly. The patient was admitted to acute in hospitalization for hypoxia in the setting of influenza A infection.

In the emergency room, the patient's oxygen saturation was 86% on room air. The patient was started on Tamiflu and Duonebs. The patient had bilateral wheezing and lower extremity edema. The patient was admitted to acute inpatient level of care for hypoxia and influenza A treatment and was continued on supplemental oxygen as well as Tamiflu and Duonebs. The following day, the patient was hemodynamically stable. The patient was weaned off oxygen to room air. The patient was continued on Tamiflu. The pulmonary consultation deemed appropriate for the patient to be discharged home.

Provision of Tamiflu, Duonebs and oxygen would be safe, effective, and consistent with the standard of care to be provided at an observation level of care. There was no treatment provided that required an acute inpatient level of care. It would have been reasonable to expect that the patient could have been treated at an observation level of care without compromising his health, safety, or outcomes. Therefore, the Inpatient admission was not medically necessary.

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