Diagnosis: Coronavirus disease 2019 (COVID-19) pneumonitis
Treatment: Inpatient emergency admission
The insurer denied coverage for inpatient emergency admission.
The denial is overturned.

This is a patient with past medical history significant for stage 4 lung cancer, hypertension, hyperlipidemia, obstructive sleep apnea (OSA), and obesity who presented to the emergency room with complaints of fever, a productive cough, shortness of breath, and pleuritic chest pain.

Vitals on presentation included: Temperature 101.8 degrees Fahrenheit, blood pressure 119/83, heart rate 115, respiratory rate 18, oxygen saturation 95% (percent) on room air. Laboratory values were notable for the following: white blood cell (WBC) count 4.7, hemoglobin 13.7, hematocrit 40.3, creatinine 0.95, glucose 112, C-reactive protein (CRP) 16.

The patient was admitted to the hospital for Coronavirus disease 2019 (COVID-19) pneumonitis. Computed tomography (CT) angiogram showed bilateral lower lobe ground-glass opacification. The patient required supplemental oxygen and was started on intravenous (IV) Remdesivir. The patient remained afebrile and hemodynamically stable. He was discharged to continue outpatient management.

Although COVID treatment and management guidelines continue to evolve, the decision to hospitalize patients with COVID infection is typically based on presence of severe dyspnea (dyspnea at rest and interfering with the ability to speak in complete sentences), oxygen saturation on room air less than or equal to 90% (regardless of severity of dyspnea), alternations in mentation (i.e. [that is], confusion, change in behavior), and other signs of hypoperfusion or hypoxia. Similarly, the National Institutes of Health (NIH) COVID-19 Treatment Guidelines Panel suggests hospitalization for patients with any of the following: an oxygen saturation of < (less than) 94 percent on room air, respiratory rate of > (greater than) 30 breaths/minute, partial pressure of arterial oxygen (PaO2)/fraction of inspired oxygen (FiO2) < 300 millimeters of mercury (mmHg), or lung infiltrates > 50 percent. According to medical records, the patient had fever, cough, shortness of breath, with tachycardia, and ground-glass findings on CT scan. Additionally, the patient had co-morbid conditions including stage 4 lung cancer. Based on above findings, the inpatient hospital admission was medically necessary.

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

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