Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory System-Asthma.
Treatment: Inpatient hospital stay.
The health plan denied the inpatient stay as not medically necessary.
The reviewer has upheld the health plan's determination in whole.

This is the case of a patient with past medical history of asthma given prednisone and antibiotics two weeks prior to presentation, obesity, hypertension, diabetes, trigeminal neuralgia, and depression who presented to the emergency department with shortness of breath worse with exertion in addition to cough associated with green sputum and one episode of vomiting. On presentation, she was afebrile with blood pressure 170/117, heart rate 107, respiratory rate 18, and with oxygen saturation 98% on room air. Exam otherwise noted wheezing without increased work of breathing or acute distress. Labs resulted with white blood cell count 12, hemoglobin 12.9, platelets 264, sodium 136, potassium 3.9, blood urea nitrogen 10.6, creatinine 1.01, troponin negative, and arterial blood gas with potential hydrogen (pH) 7.39/ partial pressure of carbon dioxide (pCO2) 39/ partial pressure of oxygen (pO2) 67.2 on room air. Chest x-ray showed no evidence of acute cardiopulmonary disease. An electrocardiogram (EKG) showed sinus tachycardia without acute ischemia. Peak expiratory flow was noted to be 300. In the emergency department, she was given prednisone, clonidine, Zofran, insulin, and nebulizers. She subsequently was noted to have continued wheezing and to have vomiting. She was brought into the hospital with concerns for asthma exacerbation secondary to bronchitis versus pneumonia and with plans for intravenous (IV) solumedrol every 6 hours, doxycycline, DuoNeb (albuterol and ipratropium) every 6 hours, ceftriaxone, follow up legionella, mycoplasma, and COVID-19, and monitor peak expiratory flow daily. The next day . Ongoing wheezing was noted without increased work of breathing. She was seen by psychiatry with note that she was stable from a psychiatric standpoint and recommendation to continue her home medications. The next day she was continued on solumedrol every 12 hours and started on amlodipine for hypertension. She was on oral steroids twice daily, oral doxycycline, ceftriaxone, and nebulizers with note of potential discharge the next morning.
Inpatient level of care was not medically necessary. This is a patient who presented with shortness of breath and wheezing concerning for asthma exacerbation without hypoxia, tachypnea, or increased work of breathing, and her noted to be in no acute distress. Given her persistent wheezing despite emergency department therapies, she was certainly appropriate to bring into the hospital for IV steroids, bronchodilators, and ongoing monitoring of her respiratory status and antibiotics therapies. It is not clear, however, why treatment could not have been safely provided with lower level of care services in the setting of no hypoxia, tachypnea, significant tachycardia, or increased work of breathing noted throughout her hospital course, in the setting of chest x-ray that was unremarkable, and with pulmonary medicine deeming her stable to discharge within a reasonable period. She subsequently appears to have stayed in the hospital in the setting of concerns for hypertension with no associated symptoms and plans to titrate her oral blood pressure medications which is appropriate to occur in a lower level of care setting.