Appeal type: Medical necessity
Decision: Upheld

The patient is a female with past medical history significant for diabetes mellitus (DM), hyperlipidemia (HLP), obesity, coronary artery disease (CAD) status/post (s/p) stenting, asthma, breast cancer status post lumpectomy, and pulmonary hypertension, who presented to the emergency room (ER) with chief complaint of shortness of breath worse with exertion over the last 3 days. She reported associated orthopnea, leg swelling, and paroxysmal nocturnal dyspnea (PND) and denied fevers, chills, cough, chest pain or other complaints.
On presentation, she was afebrile with blood pressure (BP) 146/72, heart rate (HR) 67, respiratory rate (RR) 18, with oxygen saturation of 95% on room air (RA). Exam otherwise noted decreased breath sounds bilaterally and trace pitting edema. Labs were notable for white blood cell (WBC) count 12, Hemoglobin (HGB) 9.2, comprehensive metabolic panel (CMP) within normal limits, pro-brain natriuretic peptide (BNP) 232, D-dimer 366, international normalized ratio (INR) 1.07, and troponin that was undetectable. Venous blood gas (VBG) noted pH 7.31/partial pressure of carbon dioxide (pCO2) 43. Electrocardiogram (EKG) showed normal sinus rhythm without acute ischemia or arrhythmia. computed tomography (CT)-angiogram of the chest showed no pulmonary embolism (PE) and subsegmental atelectasis in multiple lobes. The patient was subsequently brought into the hospital with plans for incentive spirometry, transthoracic echocardiogram (TTE), cardiology and pulmonary consults, supplemental oxygen as needed, and iron studies.
The following day the patient was noted to be hemodynamically stable without fever, hypotension, tachypnea or noted and was sating 96% on RA. Repeat complete blood count (CBC) and CMP were unremarkable. Duplex ultrasound (US) performed showed no evidence of deep vein thrombosis (DVT). She was seen by cardiology with recommendation that TTE and stress test be performed which showed no evidence of acute ischemia.
She continued to remain hemodynamically stable without fever, hypotension, tachypnea, or hypoxia. She continued to report shortness of breath without cough. WBC was 10. Plan was to continue bronchodilators and try by mouth (PO) steroids. With steroids, she notably had hyperglycemia in the 300s-400s.
The patient was ultimately deemed stable for discharge. 

The health plan's determination is upheld.

No, acute inpatient admission was not medically necessary. As noted above, this patient presented with shortness of breath associated with atelectasis. She did not have evidence of infection, acute coronary syndrome, acute CHF, or COPD on presentation and was hemodynamically stable without fever, tachypnea, tachycardia or hypoxia. It is noted that she remained hemodynamically stablewithout hypoxia receiving pulmonary toilet for her atelectasis and remained in the hospital primarily for subjective shortness of breath noted without other new process being treated aside from her presenting atelectasis. She underwent TTE and stress test which did not require inpatient care in the setting of this patient with normal troponin, normal EKG, and no chest pain. Monitoring at a lower level of care status for this patient with atelectasis without hypoxia or other cardiopulmonary process was reasonable for pulmonary toilet, but it is unclear why acute inpatient admission was medically necessary.