Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma exacerbation.
Treatment: Inpatient admission.

The insurer has denied coverage for inpatient admission.  The denial is upheld.

This female patient has a history of  asthma, diabetes, smoking, and hypertension.  She presented to the Emergency Room (ER) with complaints of wheezing and coughing.  She used a nebulizer and albuterol inhaler at home without relief.  A chest x-ray (CXR) revealed findings that were suspicious for pneumonia.  The physical examination revealed bilateral wheezing.  Peak flow was 150.  She was given 125 milligrams (mg) of intravenous (IV) methylprednisolone, 2 Duonebulizer treatments, and 2 g of Magnesium Sulfate.  The patient was initially admitted with an asthma exacerbation. There was a concern for chronic obstructive pulmonary disease (COPD).  The patient was started on standing albuterol and ipratropium nebulizer treatment.  One dose of IV Methylprednisolone was given and then the patient was started on 40 mg of oral (PO) Prednisone for 3 days.  She met Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria and was treated for COPD.  She was given 500 mg of Azithromycin twice a day (BID) for 3 days.  Symptoms improved, but there was still some diffuse wheezing. She was discharged home with instructions to continue Prednisone for an additional 5 days and continue home nebulizer treatments.    

The patient was in no acute distress and was speaking full sentences.  No troponin was documented.  There was no use of accessory muscles are noted.  The patient was alert and oriented.  Lung exam revealed bilateral wheeze. The patient was treated with Duo Nebs, Solumedrol, and Magnesium Sulfate. White blood cell (WBC) count was 8.3K (thousand); Hemoglobin 14. Chest x-ray showed some suggestion of retrocardiac infiltrate, but later was read as clear. The patient was subsequently admitted to the hospital. As per History & Physical (H&P) the patient was in no acute distress. Lung exam showed bilateral wheeze.  Cardiovascular system was normal.  Abdomen was soft and non-tender.

The patient remained stable after admission.  She was switched to oral (PO) Prednisone and Azithromycin.  The patient also received antitussive medications.  Peak flow was 200.  The patient was subsequently discharged home after a few days. This patient did not need acute inpatient hospitalization. She was afebrile and hemodynamically (HD) stable.  No use of accessory muscles. The patient was speaking in full sentences.  She was not hypoxic and was tolerating oral intake.  WBC and electrolytes were within normal limits (WNL).  No evidence of pneumonia, pneumothorax (PTX) or pleural effusion on chest x-ray. This patient could have been placed in observation status.  Observation could be for up to 48 hours while diagnostic testing and treatment were initiated.  This patient improved after treatment.  She could have been switched to PO meds and steroids and discharged home with ongoing follow-up in an outpatient setting.  

The health plan did act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the inpatient hospital admission is upheld.  The medical necessity is not substantiated.