Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma
Treatment: Inpatient admission
The health plan denied the requested inpatient admission as not medically necessary.
The health plan's determination is upheld.

The patient is a female with asthma (prior hospitalizations but no prior intubation, no recent systemic steroid use) who presented with 1 week of worsening shortness of breath and a cough productive of clear sputum.

In the emergency department (ED) her temperature was 98.1F., with a blood pressure (BP) of 127/85 millimeters of mercury (mmHg), a heart rate (HR) of 98 beats per minute (bpm), a respiratory rate (RR) of 18/minute, and an oxygen saturation of 96% on room air. She was in no distress, diaphoretic, but not ill appearing, her heart was regular, using accessory muscles but speaking in full sentences, no wheezes, crackles, or rhonchi, and she was alert and oriented. Labs included a white blood cell count (WBC) of 3.4, a sodium of 134, a bicarb of 22, and a blood urea nitrogen (BUN)/creatinine of 10/1.02. COVID testing was negative. A chest x-ray (CXR) showed minor opacities at base (likely atelectasis or small effusions). A computed tomography pulmonary angiogram (CTPA) found no pulmonary embolism (PE),but did find mucus plugging especially in bilateral lower lobes. In the ED, she was diagnosed with a mild asthma exacerbation and was given Dexamethasone and nebulized bronchodilators, and she did improve. A transthoracic echocardiogram (TTE) was improved from an earlier date, with a normal left ventricular (LV) size and function, and possibly basal inferior hypokinesis.
She was diagnosed with mild exacerbation of chronic bronchitic asthma and was admitted and started on Prednisone. She was seen by cardiology, who felt there was no active cardiac disease, likely pulmonary in origin, and recommended outpatient cardiology follow-up. The patient was seen by pulmonary, who recommended smoking cessation, Prednisone taper, inhalers, and outpatient pulmonary follow. They did not feel the patient needed admission. he patient was better and was discharged on a course of Prednisone and Anoro.

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

The patient presented with cough and dyspnea and was diagnosed with an asthma flare. While she had a history of an abnormal echocardiogram, she was not felt to have a cardiac explanation for her symptoms at this visit. Other pulmonary diagnoses (PE, pneumonia, interstitial lung disease), were excluded by her imaging. She was felt to have an asthma flare by pulmonary who felt she could be discharged with Prednisone and inhalers. The patient was not severely ill at presentation with no encephalopathy, hemodynamic instability, gas exchange deficit, or acute kidney injury; she was having difficulty breathing, but this improved with ED care. She did not have any of the usual findings that correlate with an increased risk of poor outcomes (prior intubation, recent steroid use, known non-compliance with or difficulty obtaining medications). The patient improved over an observation time course. Given low severity of illness, low risk of worsening, and lack of alternative diagnoses, she did not need an inpatient admission for close monitoring or inpatient only testing or treatments. She did not need an inpatient admission for prolonged symptoms. An alternate level of care would have been reasonable. She did not meet any of the inpatient admission criteria.