Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Viral Infection.
Treatment:  Inpatient Hospital Stay.

The health plan denied: Inpatient Hospital Stay.  The determination is: Upheld.

The patient is a female who initially presented to the emergency department with concerns for shortness of breath, productive cough, and chest tightness. Pertinent history included asthma without history of intubation, anemia, and hypertension. Initial vital signs revealed a temperature of 97.8 Fahrenheit, a heart rate of 121 beats per minute, a blood pressure of 154/112 millimeters of mercury, a respiratory rate of 22/minute, and a peripheral capillary oxygen saturation (SpO2) of 98% (percent) on room air. Initial examination documented the patient as alert, oriented, with tachypnea and diffuse inspiratory wheezes. Initial laboratory testing revealed a white blood cell count of 8.8, a hemoglobin of 13.5, platelets of 223, a sodium of 141, a potassium of 3.6, a blood urea nitrogen (BUN) of 6, a creatinine of 0.8, a carbon dioxide (CO2) of 21, a potential hydrogen (pH) of 7.27, a partial pressure of carbon dioxide (pCO2) of 46, and a lactate of 3.1. She was influenza A positive. Her electrocardiogram (EKG) was without acute ischemic changes. The chest x-ray was unremarkable. Corticosteroids and nebulizers were administered with clinical improvement. The tachypnea and tachycardia improved. A repeat blood gas noted a pH of 7.38, a pCO2 of 37, a partial pressure of oxygen (pO2) of 124, and a lactate of 1.4 on 2 liters per minute of supplemental oxygen via nasal cannula. The patient was placed in the hospital thereafter with an impression of acute asthma exacerbation in the setting of Influenza A. The treatment plan included systemic corticosteroids, nebulizers, and Tamiflu. The next day, the patient denied fever, chills, or dizziness. The hemodynamics were stable with no hypoxia. Mild wheezing was auscultated. There was no significant change in the treatment plan. The following day, the patient was deemed medically stable and discharged.

At issue is the medical necessity of the inpatient stay.

The health plan's determination of medical necessity is upheld in whole.

The inpatient hospital admission was not medically necessary for this patient.  The patient had a history of asthma without prior need for intubation who presented to the emergency department with shortness of breath, cough, and wheezing in the setting of an influenza A infection. Initial evaluation was concerning for tachypnea, tachycardia, respiratory acidosis, and elevated lactate. No hypoxia was noted throughout. Systemic corticosteroids and bronchodilators were provided. Following successful emergency department care, tachypnea, respiratory acidosis, and elevated lactate had resolved. Thereafter, the patient was placed in the hospital with no additional issues or complications. Following initial care, the patient was deemed medically stable and discharged with a prednisone taper.

Moreover, clinical indications for admission to inpatient care were not met. The patient did not require ventilator support nor have hypoxemia, PaCO2 elevation from baseline following emergency department care, respiratory finding that persist despite treatment, hemodynamic instability, altered mental status, cyanosis, or radiographic evidence of complication requiring inpatient treatment. 

Therefore, inpatient admission was not medically necessary.