Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma.
Treatment: Inpatient hospital stay.
The insurer denied inpatient service.
The determination is upheld.

This is a female patient with a medical history of asthma without a documented prior history of intubation. She was admitted for an asthma exacerbation secondary to an influenza infection with symptoms of shortness of breath, chest tightness and wheezing. She was treated with ipratropium and albuterol nebulizers, steroids, Tamiflu, and magnesium with an improvement in her condition. At issue is the medical necessity of an inpatient stay.
Based upon the severity of illness and intensity of required therapy, the inpatient level of care was not medically necessary. This patient with a medical history of asthma without a documented prior history of intubation was admitted for an asthma exacerbation secondary to an influenza infection with symptoms of shortness of breath, chest tightness and wheezing. In the emergency room, the patient was afebrile, hemodynamically stable, was in no acute distress, had an oxygen saturation of 96 percent (%) on room air, had a respiratory rate of 18 breaths per minute, but had accessory muscle use and wheezing on chest auscultation of the chest. She was treated with ipratropium and albuterol nebulizers, steroids, Tamiflu, and magnesium. Although the patient had wheezing on auscultation of the chest, she was in no acute distress, she was alert and awake, was hemodynamically stable, did not have accessory muscle use, was speaking in full sentences, and had an oxygen saturation of 100% on 2 liters per minute of supplemental oxygen. She did not have documented hypercapnia or documented hypoxemia/hypoxia, she did not require any ventilatory support, she did not have a sustained respiratory rate greater than (>) 30 breaths per minute or sustained heart rate >140 beats per minute, she had no reported cyanosis or increased work of breathing and her chest x-ray did not demonstrate evidence for acute infiltrates, consolidations, pneumothorax, pleural effusions, or fractures. Although the patient was placed on oxygen, she did not have documentation hypoxia or hypoxemia. Her asthma improved with the equivalent of an observation level of care. Therefore, the requested health service/treatment of inpatient services was not medically necessary for this patient.
The patient had a clear diagnosis of an acute asthma exacerbation, and she was on appropriate treatment with good response and recovery. Therefore, based on the available records and the criteria provided, it was not medically necessary for this member to be treated at the inpatient level of care, and the treatment and care could have been safely managed at a lower level of care. In addition, it would not be considered in accordance with generally accepted standards of medical practice in the United States, and clinically appropriate, in terms of type, frequency, extent, and duration; and would not be considered effective for the patient's illness, disease, and its symptoms to be admitted to an inpatient level of care. Based on the current standard of care, treatment based on credible scientific evidence in the peer-reviewed medical literature, and it is not consistent with the standards in the medical community to require an inpatient level of care.