Diagnosis: Anaphylactic Allergic Reaction

Treatment: Inpatient admission

The insurer denied the inpatient admission.

The denial was overturned.

This is a male patient with a history of multiple food allergies, prior anaphylaxis, atopic dermatitis and eosinophilic esophagitis. The patient was brought to the hospital on for an allergic reaction after accidental milk ingestion. The patient was treated with epinephrine at home and in the field (by EMS) prior to arrival to the hospital. In the Emergency Department (ED), the patient was noted to have wheezing, urticaria, tachypnea, prolonged capillary refill that prompted the need for 2 more doses of epinephrine treatment. Because of recurrent urticaria and wheezing even after initial hospital administered epinephrine treatment, the patient was admitted to the Pediatric Intensive Care Unit (PICU). The patient was treated with steroids, intravenous (IV) fluids, antihistamines/H2-blockers and bronchodilators. The patient was monitored overnight and was discharged the following next day.

Based on the review of the medical record and literature, inpatient admission was medically necessary for this patient. The patient had a prolonged anaphylactic reaction that was consistent with biphasic anaphylaxis. According to literature, biphasic anaphylaxis and ingestant allergen exposure are considered risk factors for severe anaphylaxis for a longer period. The fact that this patient required multiple epinephrine doses and was present with wheezing are also considered risk factors for severe anaphylaxis. It was thus reasonable to admit the patient who presented with several characteristics of severe anaphylaxis, to the hospital for close monitoring and treatment. The patient's acute and severe clinical presentation could not have been safely treated at a less intensive level of care than inpatient admission.

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.

Based on the above, the medical necessity for inpatient hospital services is substantiated. The insurer's denial should be overturned.