Diagnosis: Food Allergy Reaction.
Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.
The denial is overturned.

This case involves a male who was brought to the emergency department with facial swelling and generalized body itching. He does have a history of food allergies and a prior allergic reaction. The submitted documentation indicated prior to arrival he was given 10 mL (milliliters) of Benadryl. On physical examination, there was evidence of swollen lower lip and a swollen uvula. There is also swelling to the right eye. The pulmonary effort was normal and there was no evidence of respiratory distress. Oxygen saturation was 99% (percent). The documentation indicated the patient was observed for greater than 2 hours however he continued to have swelling to the tongue with a bulky uvula. There was no wheezing evident and no respiratory distress. He also did tolerate small sips of water. It was recommended he receive IV (intravenous) Solu-Medrol and Pepcid and be admitted for continued steroids and H2 (reduce acid produced by cells in stomach) blockers. The documentation detailed he continued with treatment and was able to advance to regular diet. Given these symptoms did improve he was discharged the following day.

According to the referenced literature, the patient may be admitted when there is evidence of hemodynamic instability, or when there is a need for treatment requiring inpatient care. The submitted documentation indicated this patient presented to the emergency department with facial swelling and itching. He does have a history of food allergies and it was noted that he did consume chocolate that had a nut in it. He was monitored however despite treatment and follow-up observation he continued to have swelling to his tongue in addition to a bulky uvula. While there was no sign of respiratory distress it was recommended, he be admitted for further IV medication given ongoing symptoms. Given the continued presence of swelling, the inpatient admission was needed to continue frequent monitoring in addition to allow administration of IV medications.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

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