Diagnosis: Esophageal food impaction.
Treatment inpatient hospital admission.
The insurer denied coverage for inpatient hospital admission.
The denial is upheld.

According to the documentation submitted, this is a patient with a past medical history of obstructive sleep apnea. The patient presented to the emergency room with a complaint of food obstruction.

Esophageal food impaction is a common clinical problem. The most common type of food impaction is from meat. Causes include esophageal strictures, hiatal hernia, eosinophilic esophagitis, and esophageal carcinoma. [1, 2] Diagnosis is primarily based on history and physical examination, with patients presenting with chocking/gagging, vomiting, and dysphagia and/or odynophagia. Preferred imaging is a plain chest radiograph, although it is not always required. Management involves initial assessment of the airway. Medical management often has poor efficacy. Early endoscopy is recommended and is associated with improved outcomes. [3] Complications related to endoscopic removal of food impaction include aspiration, esophageal perforation, or the inability to retrieve the food endoscopically. [1, 2]

Per clinical documentation, the patient presented, with an esophageal food bolus. The patient underwent an emergency esophagogastroduodenoscopy with removal of the food bolus. Anesthesia notes that the patient developed some wheezing and bronchospasm upon intubation. However, there were no further complications documented and the procedure continued. It was noted that he was "extubated smoothly." There is no clinical documentation demonstrating complications or abnormal vital signs after the procedure. There is no chest x-ray that demonstrated aspiration. Per Milliman Care Guidelines (MCG) criteria, inpatient admission for gastroenterology conditions are indicated for conditions, symptoms, or findings for which observation care has failed. [4] There are no indications that inpatient admission was medically necessary for this patient. Inpatient admission was not medically necessary.

The health plan acted reasonably with sound medical judgment.

Based on the above, the medical necessity for the inpatient hospital admission is not substantiated. The insurer's denial is upheld.