Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Asthma, Pregnancy
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

This is a patient who was pregnant and who presented with acute on chronic chest tightness and shortness of breath. The patient had a history of childhood asthma that is triggered by exposure to pet dander. She recently purchased a kitten for her children which had stimulated a likely asthma exacerbation. The patient had not been followed by a provider for asthma for some time. She was unable to recall the name of her maintenance medication. She reported an increase in her use of an albuterol rescue inhaler 2 times per day following the purchase of the kitten and due to increased respiratory work, the patient sought emergency care and was brought in via emergency medical services who administered 12 milligrams (mg) of Decadron, 2 grams (g) of magnesium, 0.3 milligrams (mg) of epinephrine, Combivent 3 puffs, 250 cubic centimeters (cc) intravenous (IV) fluid and was started on bi-level positive airway pressure (BiPAP). On arrival to the emergency room, there was improvement in the respiratory distress observed and she was weaned to 10 liters (L) of oxygen via a nonrebreather mask at that time. The patient underwent an ultrasound which noted an intrauterine pregnancy with suspected hydrops with pleural effusion and cystic hygroma. The patient denied any family history of genetic disorders or recent travel or systematic illness. Her blood type was B positive (+). On examination, the patient was tachycardic after receiving albuterol administration with adequate oxygen saturation. She was in no acute distress on a nonrebreather. The physical exam was noted for inspiratory wheezes in the left upper lung field and decreased breath sounds bilaterally and basilar lung fields. There was no evidence of leukocytosis seen on the lab results. A chest x-ray was also negative.

The patient was afebrile and her pulse was 94. Respirations were 17. She was in no acute distress on examination. Her oxygenation was 100%. The blood pressure was 121/56. Respiratory rate was 17. Her heart rate was 94. She had no murmurs, rubs or gallops. Her inspiratory wheezes were appreciated in the left upper lung fields and there were decreased breath sounds and by basilar lung fields with no increased work of breathing or use of accessory muscles noted. The patient had a hemoglobin of 13.1 and hematocrit 39.3%. Her basic metabolic panel was noted to be normal. Her chest x-ray was noted to be reassuring. There was a singleton intrauterine pregnancy noted with a heart rate of 147. However, the fetus was noted to have a cystic hygroma and hydrops. Cervical length was 3.4 centimeters (cm). There was gestational hypertension and asthma at presentation. The patient had an oxygen (O2) saturation at goal on 10 L nonrebreather. She was to be weaned as needed. She was also to start on albuterol ipratropium nebulizer every 4-6 hours with peak flow to be followed. A goal peak flow of greater than 300 was set. Prednisone 40 mg orally for 5 days was also ordered. She was to be on outpatient regimen of albuterol every 4-6 hours with Symbicort twice daily at 80 mg with peak flow monitoring. Asthma education was also to be continued in house. The patient's prior pregnancy history was noted for 6 prior pregnancies with 3 deliveries of which 2 were term and one was preterm. She had 2 prior miscarriages.

At presentation, her peak flow rate was 150. She was seen in consultation by pulmonary in the emergency room (ER) as well and had a diagnosis of moderate persistent asthma.
After admission, her shortness of breath improved and she was able to speak easily. The patient was weaned from oxygen overnight and denied any complaints. She had a 99% saturation on room air with a heart rate of 94 and respiratory rate of 19. She had unlabored breathing. The patient was discharged on albuterol, Symbicort, and prednisone 40 mg every (q) day. She was to followup for the fetal cystic hygroma in the outpatient setting.

At issue is the medical necessity of an inpatient stay.

The requested health service/treatment of inpatient stay was medically necessary for this patient for an acute exacerbation of moderate, persistent asthma with known trigger that required 10 liters of oxygen and nonrebreather mask therapy who was pregnant. The patient was noted to have a severe asthma exacerbation that required polypharmacy to reverse her acute condition after exposure to a cat. She required significant oxygen therapy to maintain saturations in pregnancy based upon her asthma and was gradually weaned from oxygen overnight. Thus, given a review of the records and the acute need for oxygen therapy in pregnancy, she qualified for admission to acute inpatient level of care for this single day until oxygen was weaned. She was a "pregnant or postpartum patient requiring monitoring for severe heart failure, pulmonary disease, or other comorbid condition". In this case, she was noted to be 16 weeks with severe asthma exacerbation requiring BIPAP and oxygen at presentation. This degree of impairment of oxygenation would require an acute inpatient level of care and this was supported by her asthma care. Her severe status was resolved and she was discharged to home as was appropriate. Given the recommendations of the American College of Obstetrics and Gynecology and the Milliman Care Guidelines (MCG) Care Guideline "Obstetric and Gynecologic Disease General Recovery Guidelines (GRG)", the patient was appropriate for the acute inpatient level of care.