Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma Exacerbation

Treatment inpatient hospital admission

The insurer denied coverage for inpatient hospital admission

The denial is upheld

This is the case of a female patient with history of asthma, pelvic inflammatory disease (PID), eczema and psych disorder. She presented to the emergency room (ER) with complaint of shortness of breath (SOB) and wheezing. The patient had signed out of hospital when she presented for asthma exacerbation.  Vital signs (VS) at presentation included: temperature (T) 99.1 Fahrenheit, heart rate (HR) 120. The patient was in acute distress. She was using accessory muscles of respiration. The patient was speaking in short sentences. Exam revealed bilateral (B/L) wheezing.  The patient was given subcutaneous (SC) Epinephrine, Magnesium, intravenous (IV) steroids and bronchodilators (BD). She was placed on Bilevel positive airway pressure (BIPAP).  
Labs revealed white blood cell count (WBC) 19, hemoglobin (Hgb) 11, electrolytes were within normal limits (WNL). Chest x-ray (CXR) revealed perihilar opacities and peribronchial thickening consistent with reactive airways.  The patient improved on BIPAP. She was noted to be able to speak full sentences. The patient took BIPAP off as she was unable to tolerate it.

It was decided to subsequently admit the patient to the hospital for asthma exacerbation. As per history and physical (H&P), VS: T 98.2 F, HR 97, respiratory rate (RR) 18, and oxygen (O2) saturations 97% (percent). The patient was noted to have B/L wheezing. The patient was alert and oriented to person, place and time (A X O X 3). She had taken off BIPAP as it was suffocating her. She was in no acute distress (NAD) anymore. The patient was speaking full sentences. The patient was continued on DuoNebs, oral (PO) Prednisone, Flovent. Also given Doxycycline and Flagyl for PID. The patient refused further BIPAP.

The patient remained stable after admission. She was noted to be ambulatory and not cooperative with history and exam. The patient was awake and alert in NAD Lung exam B/L wheezing/rales AxOx3 O2 sats 96 % V/S T 98 RR 18 HR 80 BP 123/59 mmHg (millimeters of mercury) O2 sats 98 %. She signed out against medical advice (AMA) later that day.

This patient did not need acute inpatient hospitalization. She could have been placed on observation status while diagnostic testing and treatment were initiated. Observation period could be for up to 48 hours. The patient was not hypoxic and was afebrile. No pneumonia (PNA), pleural effusion or pneumothorax (PTX) on imaging. She had improved with BIPAP in ED and had taken it off after a while. As per admission H&P, the patient was afebrile and hemodynamically (HD) stable. She was treated with PO (oral) medications. The patient remained stable after admission. Signed out AMA the next day.

This patient could have been treated while in Observation status. She was stable to be discharged home on PO meds the next day when she had improved with prescription (Rx). The patient was afebrile, HD stable. Speaking in full sentences and ambulatory. She was being treated with PO meds. A X O X3 and in NAD.

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

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