Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute Asthma Exacerbation

Treatment inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

The patient has a history of asthma, hypertension (HTN), and deep vein thrombosis (DVT). The patient presented to the Emergency Department (ED) with complaint of chest tightness, wheezing and shortness of breath for 3 days. She reported using her regular medications at home with no relief, so she presented to the ED.  Vital signs in the ED included a temperature of 97.5 Fahrenheit, heart rate (HR) of 105 beats per minute, respiratory rate (RR) of 20 breaths per minute, blood pressure (BP) 114/80 mmHg [millimeters of mercury], and oxygen (O2) saturation of 97% [percent] on room air (RA). Lung exam revealed expiratory wheezes with some decreased air entry. Cardiovascular system (CVS) exam revealed first heart sound (S1) and second heart sound (S2) were normal. The patient was alert and oriented. The patient's peak expiratory flow (PEF) was 200 (baseline 250). Venous blood gas (VBG) values were 7.37/50/23/28. Lactate was within normal limits (WNL). White blood cell count (WBC) was 5.5K (thousand), hemoglobin (Hgb) 14.4, arterial blood gases (ABG) values 7.37/39/149/22 99%, and electrolytes were within normal limits (WNL). Chest x-rays (CXR) revealed no acute infiltrate. The patient was treated with intravenous (IV) steroids and duo nebs.

As per ED Note, the patient was much improved. PEF was now 250 at her baseline and no desaturations were noted. The patient was dyspneic on ambulation, so she was admitted to the hospital. As per the history & physical (H&P), the patient was afebrile and hemodynamically (HD) stable. She was briefly placed on bilevel positive airway pressure (BIPAP) and then as needed (PRN). The patient was in no acute distress (NAD) and speaking full sentences. There was some wheezing on lung exam. Her breathing was unlabored. The patient was alert and oriented to person, place, and time.  The patient had complaints of some burning retrosternal pain. Troponins were done to ruled out myocardial infarction (MI). The patient was treated with proton pump inhibitors (PPI) for gastroesophageal reflux disease (GERD).  The patient was afebrile with HR- 81, RR- 20, BP- 133/89 mmHg, and O2 saturations 98% on RA. Lungs were described as clear. The patient was treated with steroids, bronchodilators, symbicort and singulair. She was also on BIPAP PRN. The patient remained stable after admission. Steroids tapered and she was discharged home the next day.

This patient did not need acute inpatient hospitalization. She could have been evaluated, treated, and monitored overnight in the outpatient (ED or Observation Status) and assessed for safe discharge the next day. The patient responded well to treatment in the ED. PEF was at baseline of 250 after treatment in the ED. The patient was afebrile and HD stable. O2 saturations were normal on RA. The patient was in NAD. No accessory muscles of respiration were being used. The patient was speaking in full sentences. No pneumonia or pneumothorax were seen on CXR. WBC and electrolytes were WNL. Arterial blood gases were unremarkable with no carbon dioxide (CO2) retention. She was tolerating oral intake. The patient could have been in observation status while diagnostic testing and treatment were initiated. She was stable for discharge the next day on oral steroids and bronchodilators with appropriate follow up appointments arranged in the outpatient setting.

The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient.

The insurer's denial of coverage for the inpatient admission is upheld. Medical necessity is not substantiated.