Diagnosis: Viral Infection.
Treatment: Inpatient hospital admission.
The health plan denied the inpatient hospital admission.
The determination is upheld.

The patient is a female with a history of diffuse large B-cell lymphoma on treatment who presented to the emergency department (ED) with concern for chest pain and shortness of breath. A home COVID-19 (coronavirus disease) test was positive, and Paxlovid was started. Initial vital signs revealed a temperature of 36.9 Celsius, a heart rate of 86 beats per minute, a blood pressure of 101/56 millimeters of mercury (mmHg), a respiratory rate of 16/minute, and a peripheral capillary oxygen saturation (SpO2) of 98 percent (%) on room air. Initial examination documented the patient as alert and oriented with normal breath sounds. Initial laboratory testing revealed a white blood cell (WBC) count of 1.79, a lactate of 0.65, and a potential hydrogen (pH) of 7.39. The COVID-19 test was positive. The electrocardiogram (EKG) was unremarkable. A chest radiograph revealed a lingular opacity. Antibiotics were initiated. The patient was admitted to the hospital thereafter with an impression of COVID-19 pneumonia. The treatment plan included remdesivir and empiric antibiotics. Remdesivir was then discontinued, and the patient was discharged on oral antibiotics.
At issue is the medical necessity of the inpatient hospital admission.
The health plan's determination of medical necessity is upheld in whole.
The requested health service/treatment of inpatient hospital admission is not medically necessary for this patient.
Diagnosis of COVID-19 is commonly made through detection of SARS (Severe acute respiratory syndrome)-CoV (coronavirus)-2 ribonucleic acid (RNA) by polymerase chain reaction (PCR) testing of a nasopharyngeal swab or other specimens, including saliva. Antigen tests are generally less sensitive than PCR tests but are less expensive and can be used at the point of care with rapid results. Evaluation and management of COVID-19 depend on the severity of the disease. Hallmarks of moderate disease are the presence of clinical or radiographic evidence of lower respiratory tract disease but with a blood oxygen saturation of 94% or higher while the patient is breathing ambient air. Patients who have mild illness usually recover at home, with supportive care and isolation. Patients who have moderate disease should be monitored closely and sometimes hospitalized; those with severe disease should be hospitalized. If there is clinical evidence of bacterial pneumonia, empirical antibacterial therapy is reasonable but should be stopped as soon as possible.[1]
The patient has a history of diffuse large B-cell lymphoma under treatment who presented with chest pain and shortness of breath. Initial evaluation found the patient to be afebrile, hemodynamically stable, and with a SpO2 of 98% on room air. Initial laboratory testing revealed a neutropenia secondary to neoplastic agents but otherwise relatively unremarkable. An EKG was unremarkable. The chest radiograph revealed findings suggestive of pneumonia. A dose of ketorolac was provided with improvement in symptoms. In summary, the patient was immunocompromised with a positive COVID-19 test but without any clinically significant findings or organ impairment. The following day, the patient was deemed medically stable and discharged. No other issues or complications were documented.
Moreover, clinical indications for admission to inpatient care were not met. The patient did not have impending or actual respiratory arrest, severe airflow or ventilation abnormalities not responsive to emergency and observation care treatment, acute bronchitis with precipitation of bronchospasm causing severe symptoms that persists despite initial care, acute bronchitis with precipitation of severe exacerbation of an underlying disease, bronchitis causing hemoptysis that is massive, severe respiratory findings not responsive to emergency and initial care treatment, or a systemic manifestation.[2][3]