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202202-146584

2022

Fidelis Care New York

Medicaid

COVID 19

Inpatient Hospital

Medical necessity

Upheld

Case Summary

Diagnosis: COVID (Coronavirus Disease)
Treatment: Inpatient Admission.

The insurer denied the inpatient admission.
The denial is upheld.

The patient is a female with history of asthma. She presented to emergency room with cough, fever, shortness of breath. Patient was diagnosed with COVID-19 pneumonia. Patient was started on supplemental oxygen and IV (intravenous) remdesivir and decadron. The patient was admitted to acute inpatient level care. The patient's symptoms improved within 24 hours and was discharged home.

No, the Inpatient admission was not medically necessary.

The patient had COVID-19 infection with pulmonary manifestations. However, at the time of admission, the patient's oxygen levels were above 90% (percent) on room air. The patient's breathing had improved. Within 24 hours, the patient's symptoms had significantly improved. The patient was hemodynamically stable. The patient was tolerating diet and was ambulating. The acute inpatient level of care is not medically necessary, as the patient could have been safely and effectively treated at a lower level of care.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.

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