Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory System - shortness of breath.
Treatment: Inpatient Hospital. 
The insurer denied Inpatient Admission. 
The denial is upheld. 

This patient is a female who presented to the hospital with shortness of breath. The symptoms started in the middle of the night and are present with rest and exertion. The patient endorsed cough with productive yellow sputum, nasal congestion, and chest tightness. However, she denied fevers, chills, nausea, vomiting, or abdominal pain. The patient went to see an ear, nose, and throat (ENT) the day of presentation but was wheezing and was given breathing treatment times (x) 2 before coming to the hospital.
Vital signs included a blood pressure of 110/73, a heart rate of 98, and respiration rate of 17. The patient was afebrile. She was placed on oxygen supplementation at a 6 liters (L) aerosol mask, saturating 99%. On exam, the patient was alert, awake and responds to voice, and was oriented x 3. There were no lesions on the skin or rash.
Laboratory studies revealed mild hypokalemia at 3.4, creatinine was 1.08, glucose was 129, and normal liver function test (LFT)s. The pregnancy screen was negative, and lactate was elevated to 2.9, with a subsequent recheck at 1.3. D-dimer was 261 with a cutoff of 229. The white blood cell count was normal. Coronavirus (COVID) testing was negative, but she tested positive for rhinovirus.
The patient was admitted to the hospital with acute bronchitis. A computed tomography (CT) scan of the chest showed peribronchial thickening and no pulmonary embolism (PE). 
The next day, the medical team reassessed the patient and found her eating in bed, without the Venturi mask, saturating 97 to 99% on room air. She still complained of chest tightness and nasal congestion but was afebrile. The rest of the exam was unremarkable. Repeat labs showed normal white blood cell count, electrolytes, and renal function. The medical team concluded that the patient's symptoms were primarily caused by infectious or inflammatory bronchitis and continued with supportive care without antibiotic treatment.
At issue is the medical necessity of Inpatient Admission.

The health plan's determination of medical necessity is upheld in whole.

The requested health service/treatment of Inpatient Admission is not medically necessary for this patient.
Of note, no room air saturation was documented by the emergency department (ED) or medical team that prompted the oxygen supplementation. Within the observation timeframe, the bronchospasm improved with appropriate anti-inflammatory treatment and no further deterioration and clinical status. The CT of the chest showed negative pneumonia, PE, and was positive for peribronchial thickening consistent with acute bronchitis. Acute bronchitis is typically caused by viral infections which do not require antibiotic treatment. The patient tested positive for rhinovirus. With supportive measures, the expectation is of gradual improvement. The documentation stated that the patient was weaned off oxygen rapidly in the first 24 hours and was ambulating without oxygen support, tolerating food, liquids, and medications.
The patient presented to the hospital with viral bronchitis caused by a rhinovirus infection that initially caused some bronchospasm. The patient was weaned off oxygen within the first 24 hours of presentation and did not require escalation and ventilatory assistance. The vital signs were stable throughout the hospitalization. There was no evidence of dehydration, as evidenced by normal labs and the ability of the patient to tolerate foods. The patient was described as resting comfortably on room air and ambulating around the room on room air. There were no major electrolyte abnormalities or renal dysfunction. There is no other evidence of severe systemic illness to warrant inpatient services.
Therefore, the requested health service/treatment of Inpatient Admission is not medically necessary.