Pharyngitis: when insurers say no, reviewers often say yes

Where the denial was overturned

A 22-year-old female has requested coverage for past emergency services provided. Findings: The physician reviewer found that the patient presented to the emergency department with a chief complaint of a sore throat and fever since the previous day. She rated her throat pain as 9 on a scale of 1 to 10. The physician noted the patient had a fever of 102.6 degrees Fahrenheit and a rapid heart rate at 112. Her blood pressure and respiratory rate were normal. Physical examination revealed tonsillar hypertrophy (left side greater than right), tonsillar exudates, and cervical lymphadenopathy. A throat culture was performed, but a rapid strep screen was not obtained. A diagnosis of “pharyngitis - strep presumed” was made, and the patient was treated in the emergency department with four medications (all given orally): Motrin, Tylenol, Norco, and penicillin.

Nature of Statutory Criteria/Case Summary: An enrollee has requested emergency room services for the treatment of her medical condition. Findings: The physician reviewer found that the patient was noted to be febrile and tachycardic in triage at the emergency department. Most importantly, however, is the patient’s self-reported inability to swallow. This is of pertinence to any patient with pharyngitis, but is of particular importance when considering the issue of early pregnancy. With inadequate oral intake, dehydration can ensue rapidly. In pregnancy, ketosis from dehydration must be avoided as severe cases can lead to failure of pregnancy. Ultimately, the patient’s apparently mild dehydration was diagnosed and treated and her pain was lessened by adequate narcotic analgesics.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for right shoulder CT (CPT 73200), neck CT (CPT 70490), cervical spine MRI (CPT 72141), and/or right shoulder MRI (CPT 73221).This patient has reported persistent throat pain, exacerbated by swallowing liquids and solids, pain involving the neck and right shoulder, as well as headaches. The provider has recommended a CT and an MRI of the right shoulder, a CT of the neck, and an MRI of the cervical spine to further evaluate the patient. According to the American College of Radiology (ACR), plain x-rays are recommended as the first imaging modalities used to evaluate patients with shoulder pain, neck pain, and cervical spine pain. X-rays will assess for a potential bone injury, and if a bone injury is identified, then CT can be performed for further evaluation of the bones.

Nature of Statutory Criteria/Case Summary: An enrollee has requested urgent care services on an emergent basis or urgent basis. Findings: The physician reviewer found that upon review of the submitted medical records, the patient presented with a moderate sore throat with the onset a short time prior. Although the patient rated her pain at 9/10, there was also documentation noting 5/10 pain rating. In addition, the patient was not experiencing a fever or difficulty swallowing or breathing. The patient had not taken any medication prior to her arrival at the urgent care center. Her vital signs were normal and the patient was not in any distress. Based on the patient’s presenting complaints and symptoms, a prudent layperson in this circumstance would not reasonably believe she was suffering from a serious medical condition.

These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for pharyngitis was denied, the published record says the denial is worth fighting.