Diagnosis: Shingles.
Treatment full hospital admission.
The insurer denied coverage for full hospital admission.
The denial is upheld.

The patient has a past medical history significant for encephalopathy after a traumatic brain injury, recurrent urinary tract infections, status post percutaneous gastrostomy tube placement, and functional paraplegia who presented to the emergency room with altered mental status. Vitals on presentation included: Temperature 98.9 F (Fahrenheit), Blood Pressure 115/76, Pulse 74, Respiratory Rate 18, oxygen (O2) saturation 96% (percent) on Room Air. Laboratory results included the following: white blood cell count (WBC) 3.9, hemoglobin (HGB)-10.6, hematocrit (HCT)-31.8, creatinine-0.87, glucose-108, urinalysis showed large leukocyte esterase, negative nitrites.

The patient was admitted for altered mental status. She was noted to have shingles over her left thigh and was started on intravenous acyclovir. She was also started on ciprofloxacin for possible urinary tract infection. Head computed tomography (CT) scan showed no evidence of acute intracranial hemorrhage or acute territorial infarction. Chest x-ray (CXR) was negative. The patient remained afebrile and hemodynamically stable. She was discharged to continue oral antivirals (acyclovir) as an outpatient.

According to documentation, the patient presented with possible change in mental status and noted to have skin rash consistent with shingles. Otherwise, the patient was afebrile, hemodynamically stable with normal white blood count (WBC). Although she had co-morbid conditions, these were chronic issues. The patient had no evidence of a disseminated infection. Based on above findings, the patient met criteria for observation level of monitoring. The patient did not fulfill criteria for acute hospital admission.

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the full hospital admission is upheld. Medical Necessity is not substantiated.