Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dyspnea, chest pain
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a history of hypertension (HTN), hyperlipidemia, diabetes mellitus (DM), pulmonary fibrosis, chronic respiratory failure on home oxygen (O2) who presented with increasing dyspnea, chest pain, and a productive cough.
In the emergency department (ED), her temperature was 98.4 degrees Fahrenheit, blood pressure (BP) 104/72, heart rate (HR) 110, respiratory rate (RR) 18, peripheral capillary oxygen saturation (SpO2) 97%. She appeared in distress, with labored breathing, no wheezes, alert and oriented. The white blood cell count (WBC) was 11.3, sodium (Na) 142, bicarbonate 21, blood urea nitrogen (BUN) / creatinine (Cr) 12/0.7, troponin (Tn) 0.0. A chest x-ray (CXR) found stable, diffuse reticular changes
The admitting team diagnosed her with acute on chronic shortness of breath (SOB) felt to be due to her underlying idiopathic pulmonary fibrosis (IPF), for which she was started on intravenous (IV) steroids, and pulmonary was consulted.
The next day she was seen by pulmonary who noted that the patient appeared comfortable and was saturating well on 2 liters (L) of oxygen, and they recommended a short course of steroids (prednisone 40 milligrams (mg) for 5 days) and consideration of a palliative care consult. Treatments were continued.
She was stable with symptoms felt to be consistent with her known diagnosis; she was breathing comfortably; treatments were continued. She was feeling better, and treatments were continued with a plan to change to oral prednisone. She was feeling better, on oral levofloxacin and IV steroids with a plan to change to oral steroids the next day. She felt at baseline. She was on oral steroids and antibiotics. The plan was for discharge, but the necessary arrangements could not be organized. She was feeling at baseline and was discharged home on a prednisone taper.
At issue is the medical necessity of an inpatient stay.
An inpatient stay was not medically necessary.
While the patient has significant disease at baseline, at presentation she had respiratory distress but no other organ dysfunction (encephalopathy, hemodynamic instability, significantly worsened or changed gas exchange, or acute kidney injury or marked electrolyte abnormality). Her respiratory distress improved with emergency department (ED) care, and by the time she was evaluated by the admitting team, she was described as comfortable. While not noted if this was the case earlier, by the next morning, it appears that she was at her home O2 flow rate. She improved over the first 24-48 hours. Scoring systems would suggest her risk of worsening and needing intensive care unit (ICU) care was low. There were no additional or alternative diagnoses.
Since she was not severely ill at presentation (the main issue was respiratory distress that resolved with ED care), was unlikely to worsen, and had no additional or alternative diagnoses, she did not need inpatient only testing, monitoring, or treatment. She improved over an ED and then an observation care time frame. The care could have been provided at a lower level than inpatient.