Diagnosis: Subglottic Stenosis.

Treatment inpatient hospital admission.

The insurer denied coverage for inpatient hospital admission.

The denial is overturned.

This was patient has a past history of asthma, allergic rhinitis, and iron deficiency anemia. The patient experienced dyspnea for some time which was misdiagnosed as asthma. The patient was observed in the emergency department and on the ward with the clinical findings of dyspnea, difficulty talking, and stridor. She noted that her dyspnea had worsened over the past few days. She had been on prednisone.
Computed tomography (CT) revealed a subglottic stenosis. A repeat CT obtained found:

"HYPOPHARYNX/LARYNX: The valleculae and piriform sinuses are well-aerated. Epiglottis and aryepiglottic folds are normal. False and true cords are normal. There is narrowing of the subglottic airway. Circumferential soft tissue is noted along the inner aspect of the proximal trachea. Soft tissue is approximately 2 cm [centimeters] in length by up to 6 mm [millimeters] in thickness. At point of greatest narrowing the airway measures 8 mm anterior to posterior by 4 mm in width"

During her hospital course she was treated with steroids and other appropriate medications. Her respiratory symptoms improved, and she was discharged for follow-up by an otolaryngologist. The peer revied literature1,2 recommends a trial of conservative therapy, e.g., oxygen and medication for initial care to avoid an unnecessary operative procedure such as a tracheostomy. The Milliman Care Guidelines (MCG) Health Recovery3 states that :

"Stridor or laryngospasm unresponsive to emergency management" is a criterion for admission.

The patient was at high risk for airway obstruction as she had obvious increasing signs - dyspnea, stridor, difficulty speaking and symptoms - stridor and objective evidence of subglottic stenosis. Her hospitalization allowed for observation and medical treatment to improve her airway to prevent obstruction.

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The patient had objective evidence of subglottic stenosis and had progressive symptoms of air way obstructions. She required hospitalization for proper care and observation that to ensure her safety if her obstruction progressed3.

The inpatient hospital admission was considered medically necessary for this patient. Her progressive airway symptoms required the proper medication and observation for possible progression her airway obstruction2,3.

The denial should be overturned as the hospitalization for the patient was necessary and in the best interest of the patient. The health plan did not act reasonably.

The insurer's denial of coverage for the inpatient hospital admission is overturned. Medical Necessity is substantiated.