202201-145838
2022
Empire Healthchoice Assurance Inc.
Indemnity
Respiratory System, COVID 19, Endocrine/ Metabolic/ Nutritional
Inpatient Hospital
Medical necessity
Overturned
Case Summary
Diagnosis: Fevers, chills, cough and Shortness of Breath
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned.
The patient is a male with uncontrolled diabetes, hypertension, hyperlipidemia, and obesity. He presented to ER (emergency room) with fevers, chills, cough and SOB (shortness of breath).
The patient was in moderate respiratory distress, along with severe metabolic acidosis, hyperglycemia and had multifocal pneumonia due to COVID 19. The patient was admitted to acute inpatient level of care for the management of acute respiratory failure due to COVID 19 and severe sepsis due to COVID 19 as well as diabetic ketoacidosis due to sepsis.
The patient was treated with IV (intravenous) antibiotics, IV (intravenous) steroids, supplemental oxygen, remdesivir, and insulin.
Yes, the Inpatient admission was medically necessary.
The patient was admitted with the diagnosis of acute respiratory failure due to COVID-19 pneumonia, severe sepsis due to COVID-19 pneumonia and uncontrolled diabetes. The patient was started on IV (intravenous) antiboitcs, IV (intravenous) remdesivir, IV (intravenous) steroids, as well as supplemental oxygen. The insulin dosage was adjusted for DM (diabetes mellitus) treatment. Despite ER (emergency room) care, the patient was in respiratory distress and had severe sepsis that would require inpatient level of care. The patient continued to have SOB (shortness of breath) and cough. The patient was seen by Infectious disease as well as pulmonary consultation. The patient remained on IV (intravenous) remdesivir, IV (intravenous) antibiotics, IV (intravenous) steroids and supplemental oxygen.
The entire admission was medically necessary, as the patient had acute respiratory failure due to COVID-19, DKA (diabetic ketoacidosis), and severe sepsis. He needed to be on IV (intravenous) antibiotics, IV (intravenous) remdesivir and IV (intravenous) steroids as well as supplemental oxygen. The proposed treatment is medically necessary, as it is the current standard of clinical practice.
No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.