Throat Infection: when insurers say no, reviewers often say yes

Where the denial was overturned

A 36-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 sore throat. The patient also felt as though her throat was swollen. She reported excessive sweating and difficulty breathing when she awoke in the middle of the night and therefore decided to go to the emergency room. In the emergency department, her vital signs were normal. The severity of the patient’s pain was documented as moderate. The patient was not short of breath while in the emergency department. Throat examination was significant for uvular swelling and swelling of both tonsillar pillars. A lateral neck x-ray was performed to assess the degree of soft tissue swelling and to rule out epiglottitis.

A 41-year-old male enrollee has requested reimbursement for emergency services he received. Findings: The patient presented to the emergency department (ED) with a chief complaint of an increasingly severe sore throat with fever for the previous five days that had not been responsive to antibiotic therapy. The ED provider noted that “…it is very painful to swallow” but the numerical level of pain was not recorded and the patient was not febrile. The patient reported that he was “spitting in a cup because it was just too painful to swallow.” The physical examination revealed a red and edematous throat, more prominent on the right side. The patient was assessed with likely cellulitis without obvious abscess formation. The patient was given augmentin and prednisone in the ED and discharged with prescriptions for the same.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for services. Group A streptococcus (GAS) is a very common cause of pharyngitis in school-aged children. It classically presents with rapid onset of sore throat and fever. The tonsils are frequently red and swollen, with a gray or white exudate. There may be associated anterior cervical lymphadenopathy, headache, abdominal pain, nausea, and vomiting. When rash is present, it is given the name scarlatina, occurring as a result of toxin production one to two days after onset of illness. Scarlet fever combines upper respiratory tract infections symptoms with a characteristic rash produced by infection with pyrogenic exotoxin-producing GAS.

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 throat infection was denied, the published record says the denial is worth fighting.