Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of breath.
Treatment: Inpatient Emergency Admission.
The insurer denied: Inpatient Emergency Admission.
The denial is: Upheld.

This case involves a female with hypertension, and chronic obstructive pulmonary disease (COPD), who presented to the emergency department with six days of worsening shortness of breath, with an associated productive cough with yellow sputum. The patient also complains of chest tightness, similar to prior asthma exacerbations. She was given a prednisone prescription and azithromycin by her primary care physician six days before this presentation but has felt no improvement. The patient has been using albuterol at home without relief. The patient reported smoking 4 to 5 cigarettes/day and marijuana.

Vital signs in the emergency department (ED) are notable for a normal temperature, pulse rate of 71, and blood pressure of 161/81. On exam, the patient has wheezes and rhonchi, decreased breath sounds but no rales. Bronchodilator treatments were provided in the emergency department, x3.
Laboratory data revealed a normal white blood cell count, electrolytes, and renal function. Venous blood gas showed a potential hydrogen (pH) of 7.43 and a partial pressure of carbon dioxide (PCO2) of 42. Coronavirus 2019 (COVID-19) testing, as well as influenza testing, were negative. Chest x-ray showed diffuse interstitial prominence representing mild pulmonary edema, with no evidence of focal pneumonia.
The patient was admitted to the hospital under medicine service, with a principal diagnosis of acute exacerbation of asthma and chronic obstructive pulmonary disease (COPD). The medical team continued the oral prednisone, started montelukast, and provided Tessalon Perles for cough. In addition, they provided a one-time dose of Lasix 40 milligrams (mg) for mild pulmonary edema and ordered a two-dimensional (2D) echocardiogram.
The patient remained in the hospital when she decided to leave the hospital, and the medical team signed her out against medical advice. Vital signs were stable, and oxygenation was 96% on room air when leaving the hospital.
The subject under review is the medical necessity for the inpatient emergency admission. 

The health plan's determination is upheld.

The inpatient emergency admission was not medically necessary for this patient. The patient has underlying asthma, continues to smoke, and is not getting relief from cough and shortness of breath at home. Chest x-ray showed mild pulmonary congestion, which resolved after one dose of intravenous (IV) Lasix. The treatment for the asthma exacerbation consisted of continued prednisone, bronchodilators, and montelukast treatment. All of these can be provided under a lower level of care status. The patient did not require invasive or noninvasive ventilatory support. The venous blood gas showed a stable pH. The patient has no significant oxygen requirement and is described as ambulatory within 24 hours of hospitalization, without respiratory distress. There is no evidence of the new onset of heart failure, as evidenced by normal brain natriuretic peptide (BNP) and normal 2D echocardiogram. As a result, the inpatient emergency admission is not indicated.