Appeal type: Medical necessity
Decision: Overturned

 Respiratory
Inpatient hospital stay

This case involves a patient with a history of anemia, asthma, recent pulmonary embolus, and morbid obesity, who presented to the hospital with a chief complaint of shortness of breath. The patient  experienced difficulty breathing with lips turning blue at home as well as associated dizziness. The patient was treated with Eliquis starting 11 days prior to this hospitalization.
Vital signs on arrival included a heart rate of 121, respirations of 24, the blood pressure was 102/50, and the patient was saturating 100%. Patient was given albuterol and Atrovent in the emergency room (ER). The physical exam showed a morbidly obese patient sitting up and complaining of dizziness and shortness of breath. Oriented x3. The neck was supple, the cardiovascular exam showed rapid S1 and S2 rhythm, and diffuse wheezing on lung exam. Venous blood gas was done, which showed a potential hydrogen (pH) of 7.36 the venous PCO2 was 49 and lactic acid at 3.3. The chemistry panel revealed normal creatinine and normal potassium. Hemoglobin was 11.1, and the white blood cell count was elevated at 18,000. The d-dimer was checked, and it showed a value of 313. The patient was diagnosed with an asthma exacerbation and a possible pulmonary embolism (PE) progression. Patient was admitted to the hospital and started on scheduled and as needed bronchodilators, Solu-Medrol 40 milligrams  intravenous  every 12 hours. Pulmonary medicine was consulted, and a computed tomography angiography (CTA) of the chest was ordered to evaluate further. Empiric antibiotic in the form of ceftriaxone was also started for this patient. At this point, Eliquis was continued for the previous thromboembolic event. The critical care specialist evaluated the patient and noted that the previous echocardiogram did demonstrate mild right ventricle (RV) dysfunction. They recommended an urgent re-evaluation of the cardiac function with an echocardiogram.  Per the internal medicine note 3 days after presentation, steroids were switched to oral, and a taper was established. Cardiology cleared the patient for discharge. Neurology also evaluated the patient and recommended to start Topamax and discontinue meclizine due to the underlying Chiari malformation. The repeat echocardiogram showed a preserved ejection fraction, no significant change from the previous study.
At this point, the patient was discharged home with a diagnosis of asthma exacerbation. The health plan's determination of medical necessity is overturned in whole. An inpatient stay is warranted and medically necessary for this presentation.
This patient had a severe asthma exacerbation and is requiring oxygen supplementation to maintain adequate saturation. There is documentation that supports the presence of nasal cannula oxygen at 2 L to maintain oxygen saturation greater than 90%. Symptoms were quite severe, and the patient required scheduled and, as needed, bronchodilator therapy, and IV corticosteroids. Given the concurrent history of a recent pulmonary embolus, this patient required an extensive evaluation and multidisciplinary approach, to ensure that the symptoms are not caused by an extension of the pulmonary embolism, which carries a high mortality risk. Therefore, it is reasonable for this patient to be admitted under inpatient status for close monitoring, aggressive treatment, and around-the-clock supervision to accomplish the desired outcome.