Diagnosis: Dysphagia
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is upheld

This case involves an adult patient under review for a prior hospital stay. The emergency department note reported the patient had complaints of difficulty swallowing. The patient had recent neck surgery. The patient also reported chest pain with swallowing. A Computed Tomography (CT) scan showed a prevertebral hematoma from C2-C6 (Cervical) compressing the esophagus. It was noted the incision was intact with no visible hematoma from the level of the skin. The patient was without airway compromise and vitals were stable. The patient was recommended for consultations with possible hematoma evacuation. The progress note reported the patient was improving. The plan was for discharge. A determination letter reported the previous hospitalization was denied as the patient could have been managed at a lower level of care. An appeal letter reported the patient presented to the emergency department with a 2-day history of an inability to swallow as well as chest pain with swallowing. The patient had recent neck surgery and a CT scan showed a hematoma with mass effect. The patient was treated with intravenous (IV) medications including steroids. The patient gradually improved, and surgery was not necessary. The facility was appealing the prior decision.

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

The inpatient admission is not considered medically necessary for this patient. In this case, the patient returned to the emergency department with a 2-day history of difficulty swallowing status post a recent cervical fusion procedure. Imaging noted a hematoma compressing the esophagus. However, the airway was intact and vital signs were stable. The documentation did not note airway restriction/obstruction or ongoing symptoms beyond observational care to support inpatient admission. Therefore, the prior denial is upheld.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient.

The medical necessity for inpatient admission is not substantiated.