Appeal type: Medical necessity
Decision: Upheld

Respiratory System
Inpatient Hospital

The patient is a female with a past medical history significant for severe persistent asthma and kidney stones who was discharged from the hospital just two days before the day of admission after she was hospitalized for acute asthma exacerbation.
She returned to the emergency department with complaints of wheezing and shortness of breath. Reportedly, she was unable to fulfill her prescription after discharge. The patient stated that she had been wheezing since she got home. The patient stated that her home was infested with roaches, dust, mold.
At the time of the initial evaluation, the patient complained of a cough that was associated with greenish sputum. She denied any fever or chills.
While she was seen in the emergency department the patient was afebrile, blood pressure was 133/85, pulse rate 89, respiratory rate 18, oxygen saturation 98%. It was reported that on exam she had bilateral wheezing.
Initially, in the emergency department, she received treatment with bronchodilators, intravenous magnesium sulfate.
When the patient was seen by the admitting physician she appeared to be in no distress. The cardiovascular exam was within normal limits. The patient was in no respiratory distress but had bilateral expiratory wheezes. The rest of the physical exam was unremarkable.
Laboratory evaluation revealed that her white blood cell count was 14.1, hemoglobin 10.9, hematocrit 32.4, platelets 212. Sodium was 138, potassium 4.4, chloride 102, bicarbonate 16, blood urea nitrogen (BUN) 9, creatinine 0.85. Liver function tests were normal. A chest x-ray demonstrated no acute infiltrates.
The patient was admitted to the hospital with moderate persistent asthma with acute exacerbation. It was documented that her peak flow was around 300 L per minute, but she had bilateral wheezing with good air entry. The patient was ordered treatment with bronchodilators, prednisone. Social services were consulted to assist with discharge planning.
According to the discharge summary, during the hospital stay patient's clinical condition improved, including her peak flow. The patient was subsequently discharged home with a prescription for corticosteroids.

The health plan's determination is upheld.

The requested inpatient stay was not medically necessary at the acute inpatient level of care, based on the mild severity of the patient's symptoms.
This patient was recovering from the previous acute asthma exacerbation and had worsening of the wheezing because of noncompliance with treatment prescribed at the time of the previous discharge.
According to the Merck Manual Professional Version, Treatment of Acute Asthma Exacerbation section, hospitalization generally is required if patients have not returned to their baseline within 4 hours of aggressive emergency department treatment. Criteria for hospitalization vary, but definite indications are
1) Failure to improve 2) Worsening fatigue 3) Relapse after repeated beta-2 agonist therapy 4) Significant decrease in partial pressure of oxygen (PaO2) (to less than [<] 50 millimeters of mercury [mmHg]) 5) Significant increase in partial pressure of carbon dioxide (PaCO2) (to > 40 mmHg)
The review of the medical records did not demonstrate that the patient had a significant exacerbation of acute asthma compared to the day of the most recent discharge.
It was reported that the patient's peak flow was 360 liters per minute (L/min) at the time of the recent discharge, and on the day of the admission it was 300 L/min, which was consistent with less than 20% decrease.
The review of the medical records revealed that at the time of the initial evaluation performed by the admitting physician this patient was afebrile, hemodynamically stable, had normal respiratory rate and normal heart rate, as well as normal oxygen saturation on room air.
The pulmonary exam demonstrated bilateral expiratory wheezing, but the patient was not in respiratory distress and had normal respiratory effort.
The review of the medical records did not demonstrate that the patient's symptoms were associated with significant hypoxemia, hypercapnia.
Taking into consideration all these facts, the severity of the patient's condition does not justify admission at the acute inpatient level of care in the otherwise stable patient who was recovering from the previous episode of asthma exacerbation. In addition, the objective evaluation of the patient did not reveal a significant worsening of respiratory status to the degree that it would necessitate an acute inpatient level of care.
The patient could have been treated at a lower level of care status.