Appeal type: Medical necessity
Decision: Upheld

Breathing Problems
Inpatient Hospital 
This patient is a G2 P1 who presented to the hospital at 28 weeks gestation with shortness of breath, nonproductive cough, chest discomfort and right leg pain. The patient had a history of receiving the influenza vaccination. The patient has a past medical history of headaches, sciatica, and exercise-induced asthma. Her reproductive history was noted that she was currently pregnant and was a G2 P1 with one living child. The patient reported having shortness of breath after a hacking dry nonproductive cough. The patient was seen by her primary medical physician where she developed mild burning and tightening sensation in the midsternal area and reported palpitations. She reported right leg pain, and was found to be tachycardic. The patient was advised by her primary medical physician to be evaluated in the emergency department for a pulmonary embolism.  She denied fever, chills, diarrhea, constipation, dizziness, tingling, numbness, abdominal pain, unexplained weight loss or gain or change in appetite. Upon arrival to the emergency department, the patient was tachycardic. A computed tomography (CT) of the chest showed no pulmonary embolism or aortic dissection. She underwent bilateral lower extremity duplex that showed no deep or superficial thrombosis. In the emergency department the patient was given 1 Liter of crystalloid fluids and was noted to have borderline low blood pressure and a heart rate in the 90s-120s. The patient's troponin and electrocardiogram (EKG) were both unremarkable. A flu swab was obtained, and the patient was saturating well on room air without oxygen. The patient was noted to have an influenza swab that was positive for influenza A and was started on Tamiflu as recommended by the pulmonary service. She was also continued on IV fluids. An EKG was performed which showed sinus tachycardia but otherwise was normal. The patient was also seen by maternal fetal medicine who assigned her a diagnosis of influenza with no evidence of cardiac pathology on lab or imaging studies. Patient was to be treated supportively with IV fluids and Tamiflu. She had not been febrile, but a plan was made to give her an antipyretic if needed. The patient also did not require oxygen. The health plan's determination of medical necessity is upheld in whole. In this case, the treatment of influenza that is accompanied by normal vital signs and therapy would not require inpatient level of care.  American College of Obstetricians and Gynecologists (ACOG) states the following: 
"Pregnant women with suspected influenza should be assessed based on a variety of symptoms, including but not limited to fever of 100.4 degrees Fahrenheit or higher, cough, fatigue, headache, and body aches. It is important to note that not all people infected with influenza will develop a fever; therefore, the absence of fever should not rule out an influenza diagnosis. Initial triage and treatment by telephone is acceptable to help reduce the spread of disease among other pregnant patients in the office. Following symptom assessment, obstetrician-gynecologists and other obstetric care providers should ask patients questions to help determine the severity of the illness. Pregnant women who cannot maintain oral fluid intake, show signs of dehydration, are experiencing difficulty breathing or pain in the chest, or exhibit any signs of obstetric complications are considered moderate or high risk and should be referred immediately to an emergency department or equivalent setting. Pregnant women who are not identified as high or moderate risk of complications but have symptoms suggestive of influenza infection can be prescribed antiviral treatment over the phone or in person in accordance with Centers for Disease Control and Prevention (CDC) guidelines". In this case, the patient, after confirmation of influenza, given her lack of risk factors, could have been treated at a lower level of care with Tamiflu. Risk factors include asthma, obstetric issues (e.g., preterm labor), or who are unable to care for themselves (e.g., obtain prescription medications or unable to tolerate oral intake) who may require inpatient care. These are not present in this case. In this case, the member was noted to have a presentation with cough and shortness of breath and leg pain. In this case, the patient was noted to be 28 weeks gestation in pregnancy. She was seen in the ER and noted to have stable vital signs with normal hypotension as seen in pregnancy. She also was noted to have a negative chest CT for pulmonary embolism or pathology and also a negative lower extremity Doppler for deep vein thrombosis (DVT). She remained stable and was afebrile. On exam, she had a regular heart rate. The patient was assigned a diagnosis of influenza by rapid flu swab that was positive for Influenza A. During the hospitalization, there were no complications of the pregnancy and the fetal status remained reassuring. There were no complications of the care provided. 
In review of the case and review of pertinent aspects of the MCG Care Guidelines, the admission to acute inpatient level of care is not supported.