Diagnosis: Anaphylaxis
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is overturned.

The patient is a male with a history of food allergy and anaphylaxis. He presented with complaint of anaphylaxis. He developed facial swelling, urticaria, and trouble breathing. EMS (emergency medical services) administered epinephrine IM (intramuscular) x2 prior to his arrive to the ED (emergency department).

On presentation to the ED (emergency department), he had elevated blood pressure and was minimally responsive with a delayed capillary refill and tonsillar hypertrophy. He was admitted to the PICU (pediatric intensive care unit). An epinephrine drip was planned. Physical exam had noted diffuse wheezing, tachypnea with mild retraction. He was treated with epinephrine, albuterol, steroids, benadryl, pepcid, combivent, supportive care including oxygen.

Yes, the Inpatient admission was medically necessary.
The patient presented with signs and symptoms suggestive of anaphylaxis. His presentation was severe and life-threatening, as he required multiple doses of epinephrine. Rebound anaphylaxis may occur after initial presentation, therefore, it is reasonable for him to have been admitted for management and observation of his anaphylaxis.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.

As above, the patient presented with anaphylaxis that required multiple epinephrine. He was appropriately admitted to the PICU (pediatric intensive care unit).