Upper Respiratory Infection denials in California external review

What the reviewers wrote

Where the denial was overturned

A 57-year-old female has requested coverage for past emergency services. Findings: The physician reviewer found that the patient presented to the emergency department with chief complaint of productive cough, congestion, dizziness, slight fever, shortness of breath and runny nose of two days duration. She reports a prior history of underlying lung disease for which she was followed by a pulmonologist. Vital signs in the emergency department included heart rate 99, respirations 18, temperature 98.1 degrees and oxygen saturation 99% on room air. The patient reported a 7 out of 10 pain level. Upon initial presentation, the patient exhibited labored respirations, cough, and decreased breath sounds. A chest x-ray was normal.

A 33-year-old female has requested coverage for past emergency services. Findings: The physician reviewer found that the patient presented to the emergency department with chief complaint of severe left ear pain, fever, difficulty hearing out of the left ear and cough for 14 days. The emergency department triage records indicate the patient began experiencing a fever earlier that day and had severe pain as well as difficulty hearing out of her left ear. The patient reported her pain as a 9 on a scale of 1 to 10. The patient’s vital signs included temperature 99.9 degrees, pulse 90, respirations 16, and oxygen saturation 100% on room air. The patient was assessed with upper respiratory infection and otitis media left ear.

Where the denial was upheld

A 28-year-old female has requested coverage for past emergency services provided. Findings: The physician reviewer found that the patient presented to an urgent care facility complaining of a one-week history of a non-productive cough, hoarse voice and chest discomfort associated with a sore throat, nasal congestion and fever. No specifics regarding the severity of the patient’s symptoms were recorded in the medical records provided other than chest discomfort and a sore throat. The physical examination revealed normal vital signs and pulse oximetry, normal pharynx and normal lung sounds. No laboratory or x-ray testing was completed. The patient was diagnosed with an upper respiratory infection, with fever, cough and throat pain.

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested emergency room services provided on an emergent basis. Findings: The physician reviewer found that review of the submitted documentation demonstrates that a prudent layperson would not have sought immediate medical attention on the date in question. Upon review of the submitted medical records, the patient presented with upper respiratory symptoms with a fever. The patient denied any shortness of breath or vomiting. She was noted to be in no acute distress. Her temperature was elevated, which resolved with administration of oral acetaminophen. No radiologic studies or laboratory testing were performed. While parental concerns were noted over the patient’s persistent fever, the patient’s symptoms were not sudden or acute in onset.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving upper respiratory infection, then check the rights and deadlines that apply to your plan.